Informatics Professor

OHSU Biomedical Informatics Education: By the Numbers

2012-01-19T09:19:00.000-08:00

This year, 2012, marks the 17th year of the Oregon Health & Science University (OHSU) Biomedical Informatics Graduate Program. What began with a half-dozen Master of Science (MS) students has grown to one of the largest programs in the country, featuring certificates and degrees, three tracks, and a large distance learning component. While informatics education actually started in 1992 with the awarding of our first National Library of Medicine (NLM) Fellowship Training Grant, we did not launch any degree program until 1996.

Now, 17 years later, the program has awarded 401 degrees and certificates to 378 people. Another 19 have completed the NLM Fellowship program without obtaining a degree, bringing the total of alumni to 397 individuals. These alumni are highly successful by any measure, having taken jobs in industry, academia, healthcare organizations, and other settings. Some have gone on to become successful faculty in the field while many more have gone on to take operational informatics roles in companies, healthcare institutions, governments, and other organizations.

The entire number of individuals who have enrolled in any of our graduate programs since its inception is 1297. The largest enrollment has been in the Graduate Certificate Program, with 974 enrollees. The total enrollment in the other programs has been 27 PhD, 217 MS, and 240 Master of Biomedical Informatics (MBI). The total number of students in all programs adds up to more than the total number of students because some have taken advantage of the "building block" structure of the program that allows students who are enrolled at one level to carry courses forward to a higher level (subject to time limitations).

The most common instance of advancing from one program to a higher level is moving from the Graduate Certificate to one of the master's degree programs. This has been done by 118 students, 41 of whom have completed the master's degree. Three individuals have advanced from the Graduate Certificate to the PhD (two being master's students along the way), while 15 out of the 27 students who have even been in the PhD program were in a master's program at some point.

The breakdown of degree and certificate graduates of the program is 11 PhD, 66 MS, 88 MBI (also including a half-dozen who completed the degree when it was called Master of Medical Informatics) and 236 Graduate Certificate. While it may seem that the program has a somewhat low graduation rate, it must be remembered that people enroll in graduate programs for reasons other than obtaining a degree or certificate. A not insignificant number of our students are already highly accomplished academically and choose a more "a la carte" path to furthering their education than obtaining a degree or certificate. Another reason for a seemingly low rate of graduation is that the program has witnessed substantial growth in recent years, meaning that many students in the program are still current students.

Students in the program have always come from a diversity of backgrounds and many bring substantial prior achievement into the program. More complete data about student backgrounds is available for those who enrolled in the program since 2007, when OHSU started doing a better job of capturing such data.

Of the 819 individuals who have enrolled in the program in 2007 or later, a total of 215 (26.3%) have prior master's degrees, 56 (6.8%) have non-medical doctoral degrees, and 211 (25.8%) have medical degrees. The most common types of master's degrees include MS (82), MBA (40), and MPH (27). The program has 26 (3.2%) individuals with explicit nursing degrees, although we know there are some other nurses who do have "nursing" explicitly in their degree titles.

Another group into which to drill down further is physicians, especially in light of the newly designated subspecialty of clinical informatics and the possibility of altered pathways for training in the future (i.e., clinical fellowships). Our physician enrollment since 2007 includes 184 MD, 15 MBBS, and 12 DO over the course of the program, with 78 MD, 6 MBBS, and 1 DO graduating. These numbers represent 25.8% of the enrollment and 30.7% of the graduates in the program. The MBI program has the highest proportion of physicians, with physicians representing 41.3% of enrollees and 38.3% of the graduates. Physicians in the program tend to be established in their careers and taking on informatics as a new career, with many already reporting professional activity in the field. The average age of physicians in the Graduate Certificate program is 47.8 years and in the MBI program is 44.2 years.

The age distribution of students enrolled since 2007 shows that those in the programs of shorter duration (Graduate Certificate and MBI) tend of be of higher age than the longer programs (MS and PhD). The average age of students in the different programs respective is Graduate Certificate 44.0, MBI 43.6, MS 35.6, and PhD 39.2.

The majority of students in the program since 2007 pursue their studies on a part-time basis. In the Graduate Certificate Program, the average duration of enrollment (including current students) is 1.5 years and the average time to graduate is 2.6 years. In the MBI program, the average duration of enrollment is 3.1 years, while the average time to graduate is 3.9 years. These numbers tend to be relatively comparable for groups with different backgrounds, i.e., those with doctoral degrees, master's degrees, or medical degrees.

The numbers reported so far represent the entire program. As noted at the onset, the program actually has three tracks. While the clinical informatics track dominates the numbers, it is important to note the other two tracks in the program.

The second track in the program is the bioinformatics and computational biology (BCB) track. This track is available on-campus only, and has subject matter that is more computational in nature. Since the launching of this track in 2007, a total of 31 students have matriculated, with 24 in the master's degree programs and seven in the PhD program. (One PhD student had a previous MS from the clinical informatics track.) The program has had 11 graduates, eight with a master's degree and three with a PhD. (One master's graduate completed both the clinical informatics and BCB tracks.) This track is likely to see growth for a variety of reasons, including from the growing role of genomics and related areas in healthcare and biomedical research as well as OHSU's continued investment in quantitative biosciences.

The third track is the health information management (HIM) track, which was launched in 2008. The motivation for this track was to bring about more integration of the HIM and clinical informatics fields, and the curriculum has been structured accordingly, with students combining classes from the clinical informatics track as well as those specific to HIM. The program is accredited by the Commission on the Accreditation of Health Informatics and Information Management (CAHIIM), which allows students to sit for the Registered Health Information Administrator (RHIA) certificate. Since inception, a total of 56 students have enrolled, 17 of whom have graduated. Of the graduates, five have sat for and passed the RHIA certification exam. Just as the American Health Information Management Association (AHIMA) is calling for the HIM entry level to move to the master's degree level, we are expanding the HIM track to the master's degree programs and seeking CAHIIM accreditation at that level.

One final part of our program is the 10x10 ("ten by ten") program. This program was started in partnership with the American Medical Informatics Association (AMIA) in 2005, when then-AMIA President Charles Safran called for one physician and one nurse to be trained in informatics at each US hospital. OHSU operationalized this definition to become 10,000 individuals trained in informatics by 2010 (hence "10x10") and became the first partner with AMIA to offer such a course, which is a standalone version of the introductory course (BMI 510) in the clinical informatics and HIM tracks of the graduate program. At the end of the course, students can optionally take the BMI 510 final exam. If they receive a B grade or better, they can then receive graduate credit for the course upon matriculating in one of the graduate programs without paying additional tuition.

At the end of 2010, a total of 999 individuals completed the OHSU 10x10 offering. Because of continued interest in the course, we have continued to offer it, and by the end of 2011, 1169 people have now completed it. Of those people, 522 (44.7%) have passed the optional final exam, and about 15% gone on to enroll in one of the graduate programs (usually the Graduate Certificate but sometimes the master's program). One individual has "run the table" of OHSU education, starting in 10x10 and advancing to the Graduate Certificate, MBI, and PhD programs.

Secondary Use of Clinical Data, the TREC Medical Records Track, and "Big Data" in Biomedicine

2012-01-18T08:19:00.000-08:00

Last week I had the opportunity to present my latest research activity at the OHSU Biomedical Informatics Conference we hold almost every Thursday during the academic year. I chose to present work about the TREC Medical Records Track and its place in the larger context of "secondary use" of clinical data in electronic health record (EHR) systems [1]. The impetus for this work grows with the increasing adoption of EHRs under the HITECH Act, along with the vision of the "learning healthcare system" [2].

I will not recapitulate the talk here, which covers the rationale, data, methods, and early results of the TREC Medical Records Track. (Details can be found on the video and slides from the talk.) I will, however, explore the relationship of what is increasingly called "big data" to biomedicine. One can easily find volumes of information on the Web about big data, but the vision is probably best articulated in the book, The Fourth Paradigm: Data-Intensive Scientific Discovery, published in 2009 by Microsoft Research [3]. This book presents visionary essays on how the growing amount of big data, from EHRs to biomolecular data to patient-entered data will facilitate new discovery of knowledge that conventional experiments will not. As other non-medical essays in the book show, this approach has led to many discoveries in other disciplines that use this form of eScience. We also know that businesses and others make productive use of the vast troves of data they collect from purchases, Web chatter, and other sources of information.

It is important to remember, however, that the existence of large volumes of electronic data does not guarantee that this data will automatically translate into knowledge. In my talk, I reviewed the unfortunately modest amount of literature on this topic. The bottom line, discussed and referenced in more detail below, is that medical records are not only incomplete, but they are also often much less meticulously kept than research data. As I have said in the past, clinical documentation is often what stands between the clinician's daily work and his or her going home for dinner. Another problem with medical records of course is that the data are observational and not experimental, so confounding factors can influence conclusions that might be drawn.

In preparing for this talk, I came across a somewhat obscure but well-written critique of big data [4]. As often happens, I found this paper almost by accident, being pointed to it by one of the email lists to which I subscribe. The primary author of the paper is Danah Boyd, who is another member of Microsoft Research and is also Research Assistant Professor in Media, Culture, and Communication at New York University as well as Visiting Researcher at Harvard Law School. (The paper was delivered as a keynote address at the Oxford Internet Institute's A Decade in Internet Time: Symposium on the Dynamics of the Internet and Society on September 21, 2011.)

Boyd and her co-author list six "provocations" for big data, which sum up to the best critique of big data I have seen. These provocations give us thoughts for concern and are all relevant to biomedicine. I list them here along with my commentary for applicability in biomedicine or other general comments:

Automating Research Changes the Definition of Knowledge - In all research, we tend to meld the question to the data we can obtain. This has certainly been true in biomedical research, where some have criticized research with answering questions either of interest to the research or that have expediency in being able to answer [5, 6, 7]. We need to remember that the data available in electronic systems, big or small, similarly impacts the questions we ask.
Claims to Objectivity and Accuracy are Misleading - Just because data are collected in a disinterested way does not mean that bias does not occur. We certainly know from the clinical documentation setting (see above or [8]) that data entered by clinicians is not necessarily accurate, objective, or complete.
Bigger Data are Not Always Better Data - This has always been known in medicine from the context of those who do "claims" research based on data collected for billing purposes, which usually consists of diagnosis and procedures codes. One argument for this type of research is the sheer volume of such data, but we also know that this data does not give a complete picture of the patient [9, 10].
Not All Data Are Equivalent - We certainly know from the clinical setting that certain types of data (e.g., data collected by motivated researchers) are more likely to be of higher completeness and accuracy than others (e.g., clinical documentation) [11].
Just Because it is Accessible Doesn’t Make it Ethical - I agree with the author that the use of Institutional Review Boards is important but also has its limitations in keeping research ethical.
Limited Access to Big Data Creates New Digital Divides - I have seen this issue play out in information retrieval research, where the researchers from the big search engine companies have access to proprietary data, which makes peer review as well as reproducibility of the work difficult at best. I know Jimmy Lin personally, and it pains me to read his comment quoted in this paper.

In summary, EHRs provide great potential for improving health and the delivery of healthcare through the learning health system, but we also must remember the caveats of doing so. The consumers of this data need to be cognizant of its limitations but also supportive of the research that explores its more effective use.

References

1. Safran, C., Bloomrosen, M., et al. (2007). Toward a national framework for the secondary use of health data: an American Medical Informatics Association white paper. Journal of the American Medical Informatics Association, 14: 1-9.
2. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29.
3. Hey, T., Tansley, S., et al., eds. (2009). The Fourth Paradigm: Data-Intensive Scientific Discovery. Redmond, WA. Microsoft Research. http://research.microsoft.com/en-us/collaboration/fourthparadigm/.
4. Boyd, D. and Crawford, K. (2011). Six Provocations for Big Data. Cambridge, MA, Microsoft Research. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1926431.
5. Harari, E. (2001). Whose evidence? Lessons from the philosophy of science and the epistemology of medicine. Australia and New Zealand Journal of Psychiatry, 35: 724-730.
6. Cohen, A., Stavri, P., Hersh W. (2004). A categorization and analysis of the criticisms of evidence-based medicine. International Journal of Medical Informatics, 73: 35-43.
7. Tunis, S., Stryer, D., et al. (2003). Practical clinical trials - increasing the value of clinical research for decision making in clinical and health policy. Journal of the American Medical Association, 290: 1624-1632.
8. Benin, A., Vitkauskas, G., et al. (2005). Validity of using an electronic medical record for assessing quality of care in an outpatient setting. Medical Care, 43: 691-698.
8. Jollis, J., Ancukiewicz, M., et al. (1993). Discordance of databases designed for claims payment versus clinical information systems: implications for outcomes research. Annals of Internal Medicine, 119: 844-850.
9. O'Malley, K., Cook, K., et al. (2005). Measuring diagnoses: ICD code accuracy. Health Services Research, 40: 1620-1639.
10. Berlin, J. and Stang, P. (2011). Clinical Data Sets That Need to Be Mined, 104-114, in Olsen, L., Grossman, C. and McGinnis, J., eds. Learning What Works: Infrastructure Required for Comparative Effectiveness Research. Washington, DC. National Academies Press.

Connecting Informatics Research to Practice: Innovations for AMIA 2012

2012-01-05T05:30:00.000-08:00

This year, I will be serving as the Scientific Program Committee (SPC) Chair for the AMIA 2012 Annual Symposium. The annual "AMIA meeting" is the most important biomedical and health informatics scientific meetings of the year, attracting the highest-quality submissions and otherwise providing a snapshot of the field through keynote talks, panels, and other sessions. I am honored to have been selected as SPC Chair for the 2012 meeting and, like many SPC Chairs before me, hope to make some innovations to the meeting that prove to be enduring in value. I was interviewed at the AMIA 2011 conference to give my perspective on the conference and my role in 2012.

The AMIA 2012 innovation I am most excited about is a new category of presentation we are calling the State of the Practice. This session type fits in well with my growing activity at the intersection between the science and practice of informatics. We hope to accept sessions led by experts and leaders from operational settings who will describe key problems and challenges whose solutions have answers in the scientific research of the field. These sessions will provide what all mature professions must have, which is robust and pertinent science that supports operational practice.

Another key AMIA 2012 innovation is a submission category for podium presentations of abstracts. As many AMIA authors and presenters know, the indexing of AMIA papers in the MEDLINE bibliographic database has been a mixed blessing. While it enables authors to have their work made more visible by indexing in the premier biomedical literature database, it also often precludes later, more substantive publication of the work in a scientific journal, due to rules around "prior publication." This new category of submission will allow authors to present their most innovative and cutting-edge work, with the abstract published in the proceedings but not indexed in MEDLINE, so that the author will retain complete flexibility for future publication of the work.

A couple other new changes will be the return of the tutorial program to presenter-initiated submissions (instead of commission by an AMIA committee) and a new pre-symposium program for AMIA Working Groups. The conference Call for Participation provides details on submitting for presentation.

Annual Reflections at Year's End: Reveling in the Successes of 2011 and Looking Ahead

2011-12-29T05:46:00.000-08:00

It has become a tradition for me in this blog to post an end-of-year message reflecting on the accomplishments (and, in recent times, thrills) of the past 12 months. This posting follows those from the end of 2009 and 2010.

It has indeed been another incredible year for informatics. Unlike past years, however, we have real accomplishments upon which to report, and not just future dreams. Most of my activity this past year has revolved around projects that are part of the Health Information Technology for Economic and Clinical Health (HITECH) Act that aims to achieve "meaningful use" of electronic health records. This has not, of course, been the main focus of everyone in informatics, as explained further below.

The main activity for me this past year has been carrying the projects that were dreamt about in 2009 and funded in 2010. Many of us still remember spending the winter holiday season of 2009 into 2010 writing proposals for the "Office of No Christmas," aka the Office of the National Coordinator for Health IT (ONC). I also remember the thrill a few months later upon learning that the two proposals I submitted had been funded, one for curriculum development and the other for training students in our graduate educational program.

There is a joke in academia that the downside of getting grants funded is that you actually have to do the work. However, the work of the ONC projects has truly been a labor of love for me. We have pretty much accomplished everything we said we would, and the results are having a mark on the field. The only sad aspect of these projects is that next year at this time, they will be winding down. We are looking at ways to achieve longer-term sustainability of both.

As noted above, however, not all that is informatics is connected to the HITECH Program. Another major source of activity is in the twin realms of clinical research informatics and translational bioinformatics. Much of this work has been enabled by the Clinical & Translational Science Award (CTSA) Program of the National Institutes of Health (NIH). Informatics has been a prominent feature in the CTSA program, leading to the development of tools and techniques that aid in the use of the data to improve the conduct of biomedical research and ultimately human health. The informatics community has also been well-organized within the CTSA framework. Although my own effort in CTSA has diminished somewhat due to the HITECH work, I am still involved in a number of roles, including working on ways to connect informatics to comparative effectiveness research (CER).

Another important area that is likely to emerge in 2012 and beyond is the informatics of personal health. We can only do so much to improve health care delivery and treatment of disease. Our field needs to pay more attention to maintaining health and preventing disease. To this end, I am pleased to see an exciting new funding opportunity from the US National Science Foundation (NSF) on Smart Health and Well-Being. We still have a lot to learn about health promotion and disease prevention. Those of us who do proactively act on maintaining our health are less prevalent than those who react to disease once it occurs. And of course, some disease just cannot be prevented no matter how healthfully we live.

I am also pleased at year's end that I have been able to sustain this blog. I have preferred to maintain this blog less like many excellent blogs that consist of the blogger's (often well-articulated) stream of consciousness. Instead, I prefer fewer but more focused and developed posts about specific topics, more like a newspaper or magazine column. I plan to continue that approach, and already have many planned postings for the weeks and months ahead. I have been so busy this fall that I have not had time to develop them.

I do wish everyone a healthy and prosperous 2012!

Update on the OHSU University-Based Training (UBT) Program: From the ONC Health IT Buzz Blog

2011-12-15T13:14:00.000-08:00

My latest update on the Office of the National Coordinator for Health IT (ONC) University-Based Training (UBT) program brings many great stories to report of graduates obtaining jobs and advancing their careers in the field. We are on track with the numbers we promised ONC we would train in our original proposal for funding, and are pleased to have the added infrastructure that the grant has afforded us. A shortened version of this posting has been adapted for the ONC Health IT Buzz Blog, but I feel compelled to tell the whole story here, keeping the material that ended up on the ONC’s virtual cutting-room floor.

About Our Program

The overall goal of the Oregon Health & Science University (OHSU) biomedical informatics graduate program is to prepare students for operational, research, and leadership roles in the application of information, usually supported by information technology (IT), to improve individual health, health care, public health, and biomedical research. Students funded by the UBT Program are expected to focus on professional and leadership roles in the implementation of the electronic health record (EHR), health information exchange, and quality measurement and improvement.

The OHSU UBT Program offers financial assistance for the Graduate Certificate (UBT Type 1 students) and Master of Biomedical Informatics (MBI) (UBT Type 2 students) programs that have been in existence for nearly ten years. In addition to financial assistance, the UBT funding requires additional specific courses (pertinent to the student’s workforce role, in place of electives) and requires students to complete a practicum (Certificate) or internship (MBI).

In the fall academic quarter of 2011, OHSU matriculated 18 Certificate and 5 MBI students. These new students commit 103 of our 135 (76.3%) Type 1 positions and all 13 (100%) of our Type 2 positions funded by OHSU’s UBT grant. Our total commitment of positions between the two programs is 116/148 (78.4%) students. The competition for funded UBT positions has been intense, especially in the Certificate program, where 327 applications have been received for the 103 committed positions (31.5% acceptance rate). Virtually all of those who have applied to the program are well-qualified, and some who were not funded have chosen to enroll as self-funded (i.e., tuition-paying) students.

The OHSU UBT program offers all six workforce roles covered by the UBT initiative. The most popular workforce roles chosen by students in the OHSU program so far have been clinician/public health leader (52, with 46 clinician and 6 public health), health IT subspecialist (29), health information management (HIM) and exchange (21), programmer/software engineer (6), privacy and security (5), and research and development (3). Of note for the HIM and Exchange role, those completing our Commission on the Accreditation of Health Informatics and Information Management (CAHIIM)-accredited curriculum for this role are eligible to sit for the Registered Health Information Administrator (RHIA) certification exam.

OHSU offers its Certificate and MBI programs both on-line and on-campus. In the UBT program, we chose to have Certificate students complete the program on-line, while MBI students were required to be full-time on-campus students. Both programs are national in scope, with students from 24 different states and the District of Columbia. Slightly over half of the students are from Oregon (54), with the other states with the largest enrollment being California (10), Washington (8), New York (4), Maryland (3), North Carolina (3), Texas (3), and Virginia (3).

Equally diverse as the geography of the students are their degrees and career backgrounds. The highest degrees for students include bachelor’s degrees (44), master’s degrees (43), MD degrees (20), PhD degrees (5), other physician degrees (2 NDs and 1 MBBS). The most common master’s degree is an MBA (9).The occupational background of our students is also heterogeneous. The most common prior careers are medicine (21) and nursing (15). Many other health care professions are represented as well, including public health, pharmacy, nurse midwifery, occupational therapy, physician assistant, speech communications, health information management, and emergency medical technician. Other highly represented occupations include business administration and management (13), computer science and information technology (9), health care administration and management (8), and library and information science (2). The variety of other occupations includes accounting, chemistry, economics, education, law, and mathematics. Three have or previously had faculty positions in higher education.

During the same time that our UBT program has been funding students, non-UBT students have also been matriculating and graduating from our programs. Since the UBT program started in the fall of 2010, 84 non-UBT students have matriculated in our Certificate program. During that same time, 32 Certificate students have graduated. Likewise, since UBT funding started, 50 non-UBT MBI students have matriculated and 13 have graduated.

A total of 25 graduates have completed our UBT Certificate program (18.5% of committed total). Another 15 are finishing up graduation requirements that should be completed before the end of the next academic quarter, while another 20-25 will be graduating at the end of the next quarter. One student has completed the UBT MBI program, with most of the first cohort of 8 students on track to complete the program on time in the spring of 2012.

Of the UBT Certificate graduates, 11 are in the clinician leader workforce role; followed by four in the HIM and exchange role; three each in the public health leader, programmer/software engineer and HIT subspecialist roles; and one in the research and development role. Six of these graduates have chosen to continue their studies by enrolling as part-time students in our MBI program.

All of our UBT graduates, and many of our currently enrolled students, have completed their practicum (Certificate) and internship (MBI) experiences. Project and settings have been diverse, from health care institutions, health information organizations, companies, and federal agencies. Health care institutions where our students have done practicum and internship activities include OHSU, Portland VA Medical Center, OCHIN (a Portland, OR-based organization that provides Epic EHR services to “safety net” clinics in several states), Kaiser Permanente (Portland, OR), Multnomah County Health Department (Portland, OR), Beth Israel Deaconess Medical Center (Boston, MA), Duke University Health System (Durham, NC), University of Utah Medical Center (Salt Lake City, UT), and Allina Health System (Minneapolis, MN). Health information organizations where students have had experiences include the Oregon HIT Extension Center (OHITEC), the Oregon Health IT Oversight Committee, and the New York Clinical Information Exchange (NYCLIX). Companies where students have had experiences include Healthways (Franklin, TN), Communication Software (Portland, OR), and Siemens Medical Solutions (Malvern, PA). Federal agencies where students have had experiences include ONC and the Department of State Office of Medical Services. Two students have completed virtual projects with the Healthcare Information Management and Systems Society (HIMSS).

About Our Students

A number of our graduates have obtained jobs in the HIT sector, some before they graduated. Some students already had jobs and used the UBT program to move into HIT or advance their careers within it. The backgrounds of these graduates are as diverse as our students, with those having clinical, IT, and other backgrounds obtaining HIT employment.

One early Certificate graduate was Tom Durkin. His previous career was as a schoolteacher, but he noted, “My wife’s solo practice as a physician gave me a window into the challenges of change and empathy for the struggles of HIT implementation.” After completing his practicum with the Oregon HIT Extension Center (O-HITEC), he was hired to recruit members for this regional extension center and to direct additional students doing the same. Additionally, Mr. Durkin will have the opportunity to develop his skills around the practice design and support of the three EHR products offered by OCHIN, the parent organization of O-HITEC. About his educational experience he stated, “The UBT program formed the basis for redirecting my teaching and sales background skills into the HIT field. The knowledge of how providers work combined with the intense depth of study in the EHR and the mandate for its universal adoption through meaningful use led directly to my current position. The OHSU program integrated an international experience through its distance learning course structure. This format provided a foundation for electronic communications that I use with providers throughout Oregon.”

Another early graduate was Edward Carroll. A former IT consultant, Mr. Carroll has taken a position with the Oregon Anesthesiology Group as Project Manager. Among his duties include IT support, implementation of new systems, product development, and process improvement activities. In describing his motivations for pursuing the program, he said, “The IT consulting market in Portland, Oregon was very fragmented and depressed economically. While looking around for a better industry where I could focus my energy and be more successful, I also decided to make that focus about giving back to society. I had been working in IT consulting for the healthcare industry for about 5 years, and decided that healthcare informatics met both criteria very nicely.”

An additional student with an IT background was Larry Bannister, a former software engineer who was the UBT program’s first MBI graduate. After completing his studies in June, 2011, Mr. Bannister immediately obtained a position as Test Manager for the Certification Commission on HIT (CCHIT). About his experience in the program he stated, “The main reason for pursuing a degree in biomedical informatics was to find work. The software engineering field has been decimated and I have been either unemployed or under-employed for a period of 4 or 5 years. I searched for something that would fit my background, as well, i.e., I wanted to utilize my software development and software test experience. I was a pre-med student as an undergraduate and continue to have an interest in the biological sciences. The OHSU program gave me the credibility to say that I have the background and training to do HIT. I had either developed or tested some HIT products in the past but the in-depth study of clinical topics, HIT legislation and HIT in general made me a more believable candidate to potential employers. Also, and most importantly, the networking via OHSU graduates and staff made the important connections that I needed to land my present job.”

Another graduate transitioning from the IT to the HIT industry was Lorraine Bessmer, who recently took a position as Applications Systems Analyst in the Information Security Group at Legacy Health Systems, a Portland, Oregon-based system of hospitals and clinics. She stated, “The Graduate Certificate program gave me the opportunity to expand my horizons and the UBT grant combined with a world-class program at OHSU was the perfect solution. With a full-time and demanding job, I could not have participated if I had to attend daytime classes. The knowledge and skills I gained during the program particularly in project management and in privacy and security provided me with the tools I needed to be successful in my practicum, which resulted in my job offer. I can say, I ‘wowed’ them.”

Ms. Bessmer further noted, “I was amazed at the enthusiasm and interest the instructors and staff all showed, and how everyone seems to genuinely want to make a difference in the lives of patients by providing clinicians with better tools so they can be more effective. I may sound jaded but this ‘enthusiasm’ was rare in my previous world. When I attended the student orientation last fall, I was amazed at the quality of the instructors and I knew the program was something I wanted to be a part of. I thought, ‘These are my people, I've found them!’”

Another graduate with a previous IT background was Gregg Hoshovsky, who has been hired as an analyst for St. Charles Health Care in Bend, Oregon. He joined the program because his previous job in e-commerce was “outsourced” to a different country. He recalled, “My basic desire was to move away from IT development positions and into healthcare business positions. The courses in this program helped me in understanding the uniqueness and complexities of the health care provider’s work environment. This has given me a better perspective in communicating and working with those professionals and to be in a better position to provide helpful solutions and suggestions for quality improvements. The courses in health care quality and the practice of health care were incredibly valuable for non-health care providers to understand the industry. The more basic classes like organizational behavior, the business of health care and the introduction to health care were helpful to gain a high-level perspective. I also enjoyed the public health classes.”

Another MBI student with an IT background, Court Fowler, is still a student in the program. However, his internship at OCHIN has led to a part-time job now and the promise of a full-time job upon graduation as a software developer. Mr. Fowler says of the program, “Without exception, all of the professors I have had for my classes have been highly capable, experienced individuals with a depth of knowledge they took pleasure in imparting to students. I have also come to value the Web-based learning management system that helps organize course material and facilitates communication among students and staff. Like those at other great schools, the program at OHSU provides a wealth of opportunities to which students can apply their efforts, and that hard work is well-rewarded with the credentials and confidence to take on future HIT challenges.”

Two physicians in the program have obtained positions as Chief Medical Information Officer (CMIO). One is Heidi Twedt, MD, the CMIO of Sanford Health in Fargo, North Dakota. She noted, “I became CMIO of Sanford several years ago, and although I had practical knowledge of our system, I lacked formal training in informatics. This led be to your 10x10 (‘ten by ten’) course and then to the UBT Certificate program.” Dr. Twedt hopes to attain certification in the new clinical informatics medical subspecialty and values the (virtual) community nature of the program, stating, “I don't have a large number of colleagues at work to talk with on these issues. I did enjoy the chat rooms and debate occurred in that forum. I just enrolled in my first class towards the MBI.”

William Jennings, MD is CMIO of the Palmetto Health Quality Collaborative in South Carolina. He recalls, “I had a desire to formalize my education at an institution considered by most to be the leader in the field, even if it was 2800 miles away. Logistically, the distance learning program allowed me to continue practicing while formalizing my education. Professionally, it vaulted me in a few months to roles in my organization that had traditionally been obtainable only after 10 or more years of service. The education that I received allowed me to not only achieve these levels in the organization, but allowed me to surpass expectations and grow my responsibilities.”

Another physician, Jodi Kodish-Wachs, MD, serves as a Physician Consultant for Siemens Corp. in Malvern, Pennsylvania. She recalls, “After implementing and utilizing an EHR as Chair of the Department Physical Medicine and Rehabilitation at a VA hospital, the dichotomy of practicing medicine in a university outpatient environment with a 7-year unfulfilled promise of an EHR was frustrating. I sought new opportunities that could satisfy my desire to improve the ability to obtain clinical information at the point of patient contact. I found I have been able to apply knowledge from every class in the UBT program to my role at Siemens. An example includes incorporating approaches from organizational behavior to address physician adoption to influencing the EHR product. The OHSU UBT clinical informatics program has exceeded my expectations. The expertise and academic openness of the professors is exceptional. Networking and employment opportunities are abundant. My new knowledge is directly applicable to both clinical medicine and industry. This led to my transition from clinical practice to employment with a vendor. I use my new information daily, applying it to the current use and future development of EHR solutions. My OHSU UBT program experiences have been invaluable to my new career in clinical informatics.”

The success of students with clinical backgrounds is not limited to physicians. Jessica Alexander is a nurse and Certificate student who serves as a nurse informaticist in OHSU Hospital. Another graduate (Certificate), Seana Zagar, works for OCHIN and is a social worker by background who now serves as Manager of Behavioral Health Product Development.

Another graduate working in HIM used the HIM & Exchange curriculum to successfully obtain her RHIA credential. Niki Newland stated, “The HIM program at OHSU has enhanced my professional life. I am staying in my current position as HIM supervisor for Providence Home Health, but have worked with my manager to revise my job description to move toward managing data quality and compliance, coding and coding education, and all parts of the revenue cycle. This directly reflects the work I did as a student at OHSU, and I find myself using the skills I learned while in the program in my work every day. The current role of the Data Quality and Compliance Coordinator is being rolled into my role of HIM Supervisor, and I have been given more responsibility when it comes to organizing and managing data that comes from quality reviews. Because I was pursuing further education and have been so successful at it, I have been granted more opportunities to participate in quality assurance and improvement work, assisting with state, CMS and Joint Commission audits and audit preparation while I was in school, and becoming the point person in Home Health HIM for those audits now that I have graduated and passed the exam.”

An additional graduate with previous experience in the healthcare industry is Jack Dainton, who used the UBT program to advance to a new position with his employer, GlaxoSmithKline (GSK, Park City, UT). Mr. Dainton’s new position title is Corporate Account Manager. The definition of his position is “to enhance the delivery and quality of patient care by providing patient centered care management solutions that will improve disease management outcomes”. He noted, “In this role I am part of a team that is attempting to take the aspects of HIT and social media and figure out how Pharma can work with these entities to interact with prescribers and patients to effectively improve health outcomes. The original and still current intent of my degree in biomedical informatics was to help me transition into an area of health care that is going to play a defining role in the success of our health care system as it continues to transform. As it turns out, my current employer, GlaxoSmithKline, also realized value in my education.”

Mr. Dainton further stated about the program, “Many employees within GSK apply for and receive educational tuition reimbursement. My employer was impressed that I applied for and received grant funding from outside of the organization and though that it showed a level of personal development and perspective that further differentiated me from other who are also continuing their education. The funding also allowed me to pursue my certificate in an accelerated fashion by providing the financing that I personally would not have been able to afford.”

He did his practicum experience at the University of Utah Health Information Services Department, noting, “This exposed me to the application of HIT in a very diverse and complex health care system. This knowledge provided me perspective on the challenges involved in maintaining an existing system, while implementing changes to improve the system to meet safety and quality goals.”

Mr. Dainton also said, “What I found most satisfying about the program was the level of passion that all students had in the area of Informatics and the realization that we are being trained in an area that is rapidly evolving and going to have serious impact on the success of the health care system in the US. I was also surprised by the level of bonding and camaraderie that took place with fellow classmates even though we had never met and our relationships were formed and existed primarily on-line or via conference calls. Since the UBT grant program at OHSU required an accelerated learning schedule, I did find the task of balancing my work life with my school commitments to be challenging, but in hind sight, very worth the effort.”

Overall, the OHSU UBT program has been a gratifying experience for students, faculty, and staff alike. There have certainly been some challenges, most notably students trying to complete the Graduate Certificate program in one year, often while holding down a job and/or family commitments, whereas most students usually take twice as long. In addition, not every student has found employment opportunities waiting at the end of their studies. While many new jobs have been created in HIT, graduates are not always a match for what is available where they want to stay living. The depressed economy has also made health care organizations and others cautious about new hiring.

Nonetheless, there are clear opportunities for the future, not only for UBT graduates but for all who are pursuing education and training in informatics. Regardless of the evolution of the HITECH program and health care reform, the health care industry will need to continue its adoption of IT. With the growing need for safety and accountability of health care, information will be a critical component for health care delivery, and no one will be better trained to perform and lead those efforts than those trained in informatics. With the development of the new clinical informatics subspecialty for physicians, and other certifications likely to follow for others in HIT, there will be professional recognition for this work as well.

More on the Clinical Informatics Subspecialty: News Report and Some (But Not All) Questions Answered

2011-11-16T12:25:00.001-08:00

The newly approved medical subspecialty of clinical informatics is sure getting a lot of press! It was certainly one of the hot topics at the recent AMIA Annual Symposium 2011. And now the iHealthBeat news site has an audio report featuring three leaders, including myself.

At the AMIA meeting, AMIA President and CEO Ted Shortliffe commented that it seemed as if 90% of his email lately consisted of questions about the subspecialty. While the percentage of my email on the topic has not been quite that high, I do get plenty of questions, especially from current, former, and prospective students of the Oregon Health & Science University (OHSU) biomedical informatics educational program.

To answer questions about the subspecialty, AMIA has developed a Web page, which it plans to build out over time, that answers specific questions. Shortliffe addressed some of the questions in his President’s Column in the November/December, 2011 issue of JAMIA [1].

This much we know for sure about the subspecialty that has been approved by the American Board of Medical Specialties (ABMS): In a first for American medicine, the subspecialty will be available to all physicians who have a primary board certification, whether internal medicine, surgery, radiology, etc.. Although the subspecialty board will be administrated by the American Board of Preventive Medicine (ABPM), any physician with primary board certification will be eligible for this subspecialty.

The initial certification of subspecialists will proceed as it has for all new subspecialties, with those having prior practice experience in the field being able to “grandfather” in on the training requirements in a “practice track” and be board-eligible, i.e., able to sit for the certification exam. Although ABPM will have the final say on what the practice-track requirements will be, the proposal to ABMS stated this track would be available to those practicing in the field a minimum of 25% time over three years or who have completed a non-accredited training program. The latter could be a National Library of Medicine (NLM) Informatics Fellowship or an educational program of a certain level, such as the OHSU Graduate Certificate or one of its master’s degree programs. But the final determination will be at the discretion of the ABPM. In the past, new subspecialties have tended to be more inclusive than exclusive with regards to practice-track requirements, but in this case, the ultimate decision-maker will be the ABPM. After five years, the practice track will no longer be available and formal training will be required in a fellowship program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

A related question is when those who are board-eligible will be able to take the exam. ABPM has indicated a hope to be able to offer the exam initially in late 2012 or early 2013.

Another common question is what opportunities for practice will be available for those who are not board-certified. Again, as with all new medical specialties, it will likely be that physicians who are not certified will still find employment in the field, at least for many years to come. I cannot imagine a battle-tested Chief Medical Informatics Officer (CMIO) losing his or her position because he or she is not board-certified. On the other hand, it could be harder going forward for those aspiring to be CMIOs to break into the field without formal training and certification.

Related to the opportunity questions are capacity questions. Will there be enough positions for those seeking training or, on the other hand, will positions go unfulfilled? The demand for training will remain to be seen. A related capacity issue is how training will be funded. At the present time, most informatics programs are offered via graduate-level education, with funding coming mainly from students paying tuition (or from a training grant, such as the NLM training grant or the University-Based Training [UBT] from the Office of the National Coordinator for Health IT [ONC]). Those in physician-training fellowships, however, are usually paid a stipend, often via the graduate medical education subsidy from the Centers for Medicare and Medicaid Services (CMS) of the US government. Clearly these physicians will be able to generate some revenue by practicing medicine, but whether it will be enough to cover the cost of fellowship training will remain to be seen.

Another educational issue is how much a tradition-bound organization like ACGME will allow fellowship programs to incorporate distance learning and other non-site-based forms of training. As we have learned at OHSU (and as I noted in the iHealthBeat report), distance learning programs are very popular for physicians and other mid-career professionals who seek to shift their careers into informatics without having to leave their job or geographical location. We have demonstrated that even practicum and internship experiences can be managed via distance, giving learners real-world experience on the ground in operational informatics settings near where they live.

I have also been asked if OHSU plans to get involved in board review courses and a clinical informatics fellowship. The answer is easier for board review; of course! Our existing curriculum has a great deal of overlap with the core curriculum for the subspecialty that was published in JAMIA in 2009 [2]. Related to this, I have been asked by physicians already in clinical informatics positions and hoping to take the exam whether they should pursue board review or traditional education, i.e., graduate education. This one is tough to answer generally, since there is a substantial knowledge base of clinical informatics, and those learning it for the first time may not learn optimally in a board review type of format. (You have to master the knowledge before you can review for the test!)

As for developing a fellowship, I certainly hope we do so, although that will require the partnership of our institution’s clinical enterprise. I also see a role for our program providing educational content to institutions that wish to offer a fellowship but do not have the educational infrastructure to support it.

Also a common question is what physicians without a board specialty can do. Unfortunately there is not much, since a medical subspecialty requires that one have a primary specialty. The good news is that AMIA has launched an Advanced Interprofessional Informatics Certification Task Force to explicitly address certification of other informatics professionals with other doctoral degrees. Hopefully an alternative pathway will be developed for others to receive comparable professional recognition in clinical informatics.

There are still questions that ABPM and ACGME must answer going forward. Like all major developments, there will likely be unanticipated consequences. But in the long run, formal recognition of informatics professionals will be positive not only for the informatics field but also for healthcare and the health of society.

(Postscript: In early 2012, AMIA posted a page of frequently asked questions about the subspecialty: http://www.amia.org/faq-clinical-informatics-medical-subspecialty.)

References

[1] Shortliffe, E. (2011). President's column: subspecialty certification in clinical informatics. Journal of the American Medical Informatics Association, 18: 890-891.
[2] Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 153-157.

Accolades for the Informatics Professor - Fall, 2010

2011-11-14T06:07:00.001-08:00

I am honored to once again be selected to be in the Modern Healthcare Magazine Top 25 Clinical Informaticists. I made the inaugural list last year and, thanks to the efforts mainly of Oregon Health & Science University (OHSU) biomedical informatics students led by Paul DeMuro, made it again this year. As noted in the overview article, I was selected mainly for the leadership role I have played in education for the field. It is quite gratifying to be among such an accomplished group and obtain recognition for my contributions to the field.

The process for selection is described on their site, along with a gallery of the awardees, including myself.

Video: Oregon Health & Science University (OHSU) Biomedical Informatics Program

2011-10-29T07:32:00.000-07:00

This week we unveiled a five-minute video describing the research and educational programs of the Biomedical Informatics Program at Oregon Health & Science University (OHSU). The easiest way to view the video is via YouTube.

The video features several of the faculty from the program who describe their research and how it synergizes with the educational program. I provide overviews of the biomedical and health informatics field as well as of the OHSU program.

The video was part of AMIA TV, a series of videos broadcast on monitors as well as hotel room television during the recent AMIA 2011 Annual Symposium. Another video features an interview of myself in my role as the Scientific Program Committee Chair for next year's meeting.

My AMIA: The Professional and Personal Importance of a Professional Society

2011-10-22T15:20:00.000-07:00

I am off this weekend to one of my favorite events of the year, which is the AMIA Annual Symposium. I have attended the Annual Symposium, called by different names over the years, every year since I first entered the biomedical and health informatics field in 1986.That makes this year's AMIA 2011 meeting the 26th consecutive year of attendance for me.

The AMIA meeting serves many purposes for me. First and foremost, of course, is that I get informed and updated on the latest advances in the informatics field. But the value is not limited to the science. Featured speakers and panels give updates on policy and other key happenings. Social and other events allow networking and catching up with old colleagues and friends and making new ones. It is also one of the most exhausting meetings I attend, as all the sessions and other activities keep me busy each day from early morning until late at night.

An organization like AMIA drives home to me how important one's professional organization is in a scientific or professional discipline. Not only do I count my closest colleagues in AMIA, but also many of my best friends. Another critical asset of AMIA is its staff, which is not only incredibly competent, but whom I also include among my most important colleagues and friends. AMIA also gives the support and collaboration for initiatives such as the 10x10 ("ten by ten") program, which former AMIA President Don Detmer has called one of the organization's most successful programs ever.

AMIA is really like a family to me. My colleagues and friends are always there for me, and I was tickled to learn recently that I am the singular person to have attended every AMIA meeting in the 21st century.

Next year's AMIA Annual Symposium will be even more special for me. In my 27th consecutive symposium attended, I will be serving as Scientific Program Committee Chair. This is a great honor but also one that carries significant responsibility. Not only must the program reflect the highest quality scientific presentations, but must also include other events that capture the larger perspective of the field and the role it is playing in improving individual health, healthcare, public health, and biomedical research.

The meeting next year will be made more special by its location in Chicago. While not the first time it has been in the Windy City, it will be special to have the conference I am chairing take place in my home town. Even though I know longer live in Chicago, it is where I grew up and did all of my education and medical training. I am hopeful that some of my family will also be able to attend some of the meeting. I hope everyone else reading this will also consider sharing in the fun as well.

Update: Clinical Informatics Subspecialty Approved

2011-09-23T15:14:00.000-07:00

Several months ago, I described the proposal to establish a medical subspecialty in clinical informatics. I am pleased to report that this week, the American Board of Medical Specialties (ABMS) approved the subspecialty, as noted in a news release from AMIA.

Although administered by the American Board of Preventive Medicine, the subspecialty will be available to all physicians who have a primary board certification. The first offering of the examination will likely take place in the fall of 2012 for those who meet the criteria for "grandfathering" of the training requirements. In the long run, physicians wanting to subspecialize in clinical informatics will need to complete formal fellowship training.

The approval of this subspecialty is a recognition of the critical professional role played by clinical informaticians. As information is so critical to 21st century medicine, whether in the need for healthcare to be more accountable for its operations or in the coming complexity of clinical decision-making from the data "tsunami" due to advances in genomics and related areas, there will be increasing need for those who work at the interface of medicine and information systems.

There are a number of uncertainties in this development. For example, what will be the criteria for grandfathering of the training requirements. Also, what career pathway will there be for physicians who are not certified in a primary board or have let that certification lapse? Another concern is what will be the evolving role for graduate-level educational programs, such as our program at Oregon Health & Science University.

Although there are a number of details still forthcoming, this new development is an exciting one for the informatics field. I also hope that there will be other pathways for comparable certification not only for physicians who are not eligible for ABMS certification but also for informatics professionals of other backgrounds, both clinical and non-clinical.

More Studies Assessing Quality Improvement Using Electronic Health Records

2011-09-11T13:28:00.000-07:00

Earlier this year, the informatics world was abuzz with a study published in Archives of Internal Medicine by Romano and Stafford that found a lack of improvement in healthcare quality measures for patients whose physicians had adopted electronic health records (EHRs) [1]. As I detailed in a posting to this blog, as well as in a co-authored letter to the editor that was published in Archives [2], this study had a number of flaws. My main complaint with the study was that the quality measures assessed were independent of the EHR intervention, hence any association, positive or negative, was indirect at best.

The furor about the paper died down, and most people got back to working on implementing meaningful use. No one disagreed that we need more research on whether EHR systems do improve healthcare quality, including studies with better methodology.

Last month, another study came along. Published in the New England Journal of Medicine (NEJM) by Cebul et al., this study used a somewhat similar methodology to assess 46 practices in the Cleveland area, 33 of which had adopted EHRs [3]. The study assessed the outcomes of 27,207 patients with diabetes mellitus who were followed by a total of 569 providers. The study looked at four process measures and five outcome measures in those diabetic patients, comparing them for providers who had and had not adopted EHRs. Overall composite quality measures were developed for the process and outcome measures, and found to be 35.1% higher in the former and 15.2% higher in the latter. The difference was found to persist across all insurance types and, even more gratifying, for "safety net" clinics that historically see more complicated patients of lower socioeconomic status.

This study did use a roughly similar methodology to the Romano and Stafford study, and as such must be viewed as having a weaker form of evidence than a direct randomized controlled trial (RCT). Of course, in reality, such an RCT would be near impossible to do, i.e., randomizing patients to receive their care from a provider having an EHR or not. We also know that there can be confounders between practices utilizing and not utilizing EHRs.

Nonetheless, this study did have advantages over similar studies done before it, including the Romano and Stafford study. One clear advantage was that the study had complete data on all patients (unlike the Romano and Stafford study that only relied on a data set from the CDC National Center for Health Statistics (NCHS). The researchers also had precise data on the providers, the EHR implementation, and how the quality measures were integrated into the provision of care.

While this new study received a great deal of press, another study that received less press, which was published shortly after the publication of the Romano and Stafford study, should have received more [4]. Although still not an RCT design, this study did use a before-and-after methodology to examine change in compliance with 16 quality measures before and after implementation of a commercial EHR in a large academic internal medicine practice. The results showed improvement after the EHR was implemented.

In an editorial accompanying the Cebul et al. study, Classen and Bates noted that the new NEJM study showed the "meaning in meaningful use" [5]. They correctly point out that implementing EHRs is not what HITECH should be about, but rather showing that the technology can be used to make meaningful improvement in the health of patients whose providers use it. As in most areas of medicine, we cannot wait for the perfect study or studies to answer all questions unequivocally, but the evidence base is growing for the value of informatics, especially when systems are implemented properly.

References
1. Romano, M. and Stafford, R. (2011). Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives of Internal Medicine, 171: 897-903.
2. Mohan, V. and Hersh, W. (2011). EHRs and health care quality: correlation with out-of-date, differently purposed data does not equate with causality. Archives of Internal Medicine, 171: 952-953.
3. Cebul, R., Love, T., et al. (2011). Electronic health records and quality of diabetes care. New England Journal of Medicine, 365: 825-833.
4. Persell, S., Kaiser, D., et al. (2011). Changes in performance after implementation of a multifaceted electronic-health-record-based quality improvement system. Medical Care, 49: 117-125.
5. Classen, D. and Bates, D. (2011). Finding the meaning in meaningful use. New England Journal of Medicine, 365: 855-858.

Update of Site, What is Biomedical & Health Informatics?

2011-09-05T21:54:00.000-07:00

Years ago, I used to get asked on a regular basis, What is Medical/Biomedical/Health Informatics? To answer this question, I created a Web site that attempted to answer it. Later on, I added some voice-over-Powerpoint lectures, which also provided me the opportunity to demonstrate the technologies we use in our distance learning program at Oregon Health & Science University (OHSU). In 2007, the site was accepted for listing in the Association of American Medical College (AAMC) online medical educational resource, MedEdPortal.

Keeping a site like this up to date is no small feat, especially at a time like this, when many people in the field are very busy carrying out work related to the Health Information Technology for Clinical and Economic Health (HITECH) Act. As readers of previous postings in this blog know, I have been very busy leading OHSU's contributions to the HITECH Workforce Development Program.

For this reason, the site had grown out of date, with its last major update in 2009, when the HITECH Act had just been passed. I am pleased to announce that I have now updated the lecture and references on the site to include not only everything related to HITECH, but also advances in other areas of biomedical and health informatics, including bioinformatics, information retrieval, and telemedicine.

The site still includes my voice-over-Powerpoint lectures, which have now expanded to about 2 hours and 40 minutes, but are still divided into seven segments. On almost every slide, I could go into even more detail. If nothing else, this site will hopefully whet peoples' appetites for the 10x10 program, the OHSU graduate program, or other programs.

The educational methods I use on this site mirror my on-line teaching. I have always found great value in voice-over-Powerpoint lectures, especially using the Articulate tool that provides the slides and sound in Flash format and also allows easy navigation among the slides. I also provide MP3 files of the slide audio (one MP3 per segment) as well as PDF files of the slides themselves (one PDF per segment). In addition, I provide another PDF that has references to all of the papers, reports, books, and other citations in the lecture. The site also contains a list of key textbooks as well as links to some of my papers and to important organizations and other sites for the field.

I look forward to receiving feedback from people and take full responsibility for any errors in any of the materials I have produced.

The Passing of a Giant: Senator Mark O. Hatfield (1922-2011)

2011-08-18T15:49:00.000-07:00

Oregonians and indeed many Americans of all political stripes mourned the passing last week of a truly great politician whose statesmanship and bipartisanship seem almost like an anachronism in contrast to our current hyper-partisan, 24-hour news cycle-driven political gridlock. Former Oregon Sen. Mark O. Hatfield was a politician who transcended party and ideology and whose work led to true benefit for large numbers of people, not only those living in Oregon.

While many politicians are an abstraction to most people, impacting their lives only in indirect ways, Sen. Hatfield was personal and real in my life. My presence and success at Oregon Health & Science University (OHSU) as well as the flourishing of our Department of Medical Informatics & Clinical Epidemiology (DMICE) have their origins that can be attributed to Sen. Hatfield.

I personally would not be in Oregon were it not for the "earmark" established by Sen. Hatfield for OHSU under the National Library of Medicine (NLM) Integrated Advanced Management Information Systems (IAIMS) program in the 1980s. I know that political earmarks have a bad name now, but the IAIMS earmark to OHSU was an investment that launched nationally prominent programs in biomedical informatics and clinical epidemiology and shows that such investments can bring true and lasting value. From a financial standpoint, the returns on this investment have accrued manyfold times over for OHSU and the Oregon economy. And perhaps more importantly, the scientific accomplishments and training of future generations of professionals and leaders have even larger returns beyond the financial.

Sen. Hatfield may not have been an expert in informatics or clinical epidemiology, as few people were in the 1980s, but his attaching an earmark to the IAIMS initiative shows that in the 1980s, he had the foresight to see the future potential for these fields in health and biomedicine. He was also a tireless crusader for all types of funding for biomedical research as well as higher education throughout his career.

Sen. Hatfield's political views were different but consistent. He truly matched a label we almost never see any more, namely a "liberal Republican." Sen. Hatfield characterized the proper meaning of the word "liberal." He was a proponent of free markets and economic liberty when they made practical sense, but also recognized when they did not, such as in education and health care. He was an advocate for national defense but opposed military adventurism, best exemplified by being a World War II veteran but also an early opponent of the Vietnam War. Sen. Hatfield recognized the proper role of government in a capitalist society, and it is unfortunate that modern opponents of true liberalism have been able to so successfully redefine the word and the political meaning and actions of those who are true liberals.

I did not agree with all of Sen. Hatfield's political positions. For example, his pacifism and reverence for life led him to oppose the reproductive rights of women. However, I can laud him for consistency in his views of truly being "pro" life, not only opposing abortion, but also capital punishment, corporate misbehavior, and military overreach.

Just as Oregon will miss Sen. Hatfield, it is to our country's detriment that there are not more politicians like him, whether they affiliate themselves with the Republican or Democratic Party. I am not sure Sen. Hatfield would be revered by most leaders of the current Republican Party, although unfortunately, most modern Democratic Party leaders would eschew him also. But rejecting statesmen like Sen. Hatfield will only be to our detriment. The real problems of our debt, unemployment, runaway healthcare costs, and many more will only be solved by people and leaders who place political pragmatism over ideology and those who consider all facts instead of their selective interpretation to score political points. Whether Republican or Democratic, we need more people like Sen. Hatfield back in our political system and dialogue, and this is all the more reason why we should truly mourn his passing.

Although I did not know him well, Sen. Hatfield touched my life and enabled my success. For that reason, I will laud him as well as miss him and people like him.

Identifying Patients for Clinical Studies from Electronic Health Records: The TREC Medical Records Track

2011-08-01T21:22:00.000-07:00

The substantial federal investment devoted to electronic health record (EHR) adoption in the Health Information Technology for Economic and Clinical Health (HITECH) Act brings many potential benefits to health care. In addition to the improved availability of information about patients during the delivery of care is the ability to better “learn” from what we do in health care so we can better understand what works and what does not [1]. This is one aspect of how we will benefit from the secondary use (or re-use) of clinical data in EHRs [2].

Another substantial federal health care-related investment is in “comparative effectiveness research” (CER), which focuses medical research (e.g., clinical trials) on critical health care-related questions in head-to-head comparisons in real-world settings [3]. A total of $1.4 billion of funding in the American Recovery and Reinvestment Act (ARRA) was allocated for CER, with a mandate to establish the Patient-Centered Outcomes Research Institute (PCORI), a public-private entity to prioritize the investment in CER. One of the first products of the government’s CER efforts was a list of the top 100 priority clinical conditions, developed by the Institute of Medicine (IOM), to guide CER efforts and funding at the federal level.

In the meantime, there have been other federal investments in using health IT to facilitate clinical research. One of these is the National Institutes of Health (NIH) Clinical and Translational Research Award (CTSA) program, which funds 60 centers nationwide to facilitate translational research. Another effort comes from the Strategic Health IT Advanced Research Projects (SHARP) Program of the HITECH Act, which funds four priority areas of research in health IT, including the secondary use of clinical (including text) data.

Against this backdrop of government and other investment in health information technology comes a new track in the Text Retrieval Conference (TREC), an annual challenge evaluation hosted by the US National Institute for Standards & Technology (NIST). TREC is a long-standing event that builds “test collections” allowing different approaches to information retrieval (IR) to be assessed in an open and comparable manner. Each year, a number of “tracks” are held within TREC devoted to different aspects of IR, such as Web searching or cross-language IR [4]. While TREC is focused on general IR, there have been some tracks devoted to IR in specific domains, one of which in the past was genomics [5].

This year, TREC has launched a Medical Records Track. With TREC’s focus on IR, the goal of the track is to develop a task that is both pertinent to real-world clinical medicine and within the scope of IR research. The track is fortunate to have received access to a large corpus of medical text that has been de-identified. These documents are organized as visits (or encounters). The de-identification process prevents linking multiple visits for a single patient. The retrieval task in the first year of the TREC Medical Records Track will be one of retrieving cohorts of patients who would fit criteria to participate in clinical studies. The retrieval “topics” will come from the IOM list of CER priority conditions, modified to create unambiguous and an appropriate quantity of retrieved documents. OHSU has received a grant from NIST to organize the topic development and relevance assessment processes of the track.

The documents for the task come from the University of Pittsburgh NLP Repository, a repository of 95,702 de-identified clinical reports available for NLP research purposes. The reports were generated from multiple hospitals during 2007, and are grouped into “visits” consisting of one or more reports from the patient’s hospital stay. Each document is formatted in XML, with a cross-walk table that matches one or more documents to visits. There are a total of 17,199 visits.

Each document contains four sources of information that can be used for the task:

Chief complaint
Admit diagnosis (as ICD-9 code)
Discharge diagnosis(es) (as ICD-9 code)
Report text

The documents come from a number of different report types:

Radiology Reports - 47,555
History and Physical Exams - 15,721
Emergency Department Reports - 13,424
Progress Notes - 8,538
Discharge Summaries - 7,931
Operative Reports - 5,032
Surgical Pathology Reports - 2,877
Cardiology Reports - 632
Letter - 1

The task will require relevance assessments for each visit, with retrieval performance measured by recall, precision, and related measures (e.g., mean average precision – MAP) based on the assessments. As with all TREC relevance assessments, retrieved visits will be pooled based on the top N documents for each run of each participating group, where N is a number that will yield a pool of about 300-400 documents for assessment. The test collection will contain 35 topics.

The relevance assessment process will proceed similar to the typical TREC approach. Retrieved documents will be assessed by relevance judges who have clinical backgrounds. They will assess for each topic whether a visit is definitely relevant (patient would meet the criteria to be a subject in a clinical study), possibly relevant (patient might meet the criteria to be a subject in a clinical study), or not relevant (patient would not meet the criteria to be a subject in a clinical study). We will ideally have one person perform all the relevance assessments for a given topic.

I have had the opportunity to be involved in leading a number of IR challenge evaluations over the years, not only in genomics, but also devoted to interactive IR [6] as well as retrieval of medical images [7]. The TREC Medical Records Track is very timely given the growing interest in leveraging the large ongoing investment in EHRs and working toward a learning health system.

References

1. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29.
2. Safran, C., Bloomrosen, M., et al. (2007). Toward a national framework for the secondary use of health data: an American Medical Informatics Association white paper. Journal of the American Medical Informatics Association, 14: 1-9.
3. Murray, R. and McElwee, N. (2010). Comparative effectiveness research: critically intertwined with health care reform and the future of biomedical innovation. Archives of Internal Medicine, 170: 596-599.
4. Voorhees, E. and Harman, D., eds. (2005). TREC: Experiment and Evaluation in Information Retrieval. Cambridge, MA. MIT Press.
5. Hersh, W. and Voorhees, E. (2009). TREC genomics special issue overview. Information Retrieval, 12: 1-15.
6. Hersh, W. (2001). Interactivity at the Text Retrieval Conference (TREC). Information Processing and Management, 37: 365-366.
7. Hersh, W., Müller, H., et al. (2009). The ImageCLEFmed medical image retrieval task test collection. Journal of Digital Imaging, 22: 648-655.

Postscripts: Noteworthy Mentions and Links

2011-07-09T06:06:00.000-07:00

This posting is devoted to some postscripts on items covered in prior postings.

First, the public rollout of the Health IT Curriculum, funded by Office of the National Coordinator for Health IT (ONC), has received many mentions in the press. Among the more notable include:

Second, a well-produced version of a recent talk of mine has been posted on YouTube by my colleagues in the Department of Biomedical Informatics at Ohio State University.

National Library of Medicine: An Informatics and Government Agency Exemplar

2011-06-26T16:33:00.000-07:00

This week I am off to another meeting I attend every year, which is the National Library of Medicine (NLM) Informatics Training Conference, the annual meeting held for all trainees funded under the NLM Biomedical Informatics Training Grant Program. Also in attendance are program directors and faculty, NLM staff, VA informatics trainees, and a variety of other people. The meeting varies between being held at the NLM and the various sites; OHSU hosted the meeting in 2009.

At a time when Americans increasingly question the function and value of their government and its agencies, the NLM is a shining testament to the good that the public sector can perform. It is hard to imagine a private entity carrying out the mission of NLM, especially as successfully as it has done so.

The NLM is the world's medical librarian, providing an entry way into the biomedical literature for anyone on the planet who types pubmed.gov into a browser. (The Pubmed system provides access to the MEDLINE bibliographic database, which contains the title, abstract, source information, and other metadata about scientific journals articles in biomedicine.) Even though most of the articles referenced in MEDLINE are from commercial publishers and not freely accessible, NLM delivers users to the publishers' electronic doorsteps. The NLM and its talented scientists and developers have pushed the envelope in many other areas as well, from genomics to imaging to public health. The NLM serves not only researchers and clinicians, but also consumers and policy makers.

Another critical role of the NLM is its scientific leadership in the field of biomedical and health informatics. The NLM funds research in informatics as well as the training of future scientists and leaders. While not the only federal agency involved in the use of information technology in health and biomedicine, it is clearly the foundational leader that facilitates the basic research to inform others who apply it.

No small part of the NLM's success is due to its excellent leadership in Donald AB Lindberg, MD, who has guided the Library for over two decades, longer than I and many others have been in the field. Dr. Lindberg has been remarkably prescient over the years. I remember him touting the virtues of the Human Genome Project when I was an NLM informatics trainee in the late 1980s. Subsequently he has been spot on in his seeing the development of new venues for publishing as well as the desire for patients and consumers to access health information online.

The NLM also has longevity. It has an illustrious history, dating back to its inception as the The Library of the Office of the Surgeon General of the Army, led in its early days by John Shaw Billings, MD. This year is the NLM's 175th year anniversary.

I have a great deal of gratitude for the NLM personally. Like many who work in informatics, my career would not be what it is without the help of NLM. I entered the field in a postdoctoral fellowship directly out of my medical training in 1987. The three years of fellowship funded by NLM allowed me to gain knowledge and skills as well as prepare for an academic career in the field. After completing my informatics training, I landed a faculty position at Oregon Health & Science University (OHSU), funded by a grant to OHSU under the Integrated Advanced Information Management Systems (IAIMS) program, an NLM initiative to develop the informatics human and technology infrastructure at academic medical centers. (In the 21st century, these activities are a normal part of doing business at academic medical centers.) The director of the OHSU IAIMS program, who recruited me to that first job, J. Robert Beck, MD, also obtained an NLM informatics training grant at OHSU, of which I now serve as PI and Director.

The NLM has also funded my research over the years, not only providing the resources for my own scientific contributions to the field but also giving me the experience and latitude to develop other aspects of my career. My first grant ever was a First Independent Research Support & Transition (FIRST) Award (also known as an R29). Since then I have had a number of subsequent grants both for research and education of trainees. These projects, from research to teaching, have enabled me to touch the life of countless others who have also achieved success in their careers in the field.

While it is obvious that the US government needs to make some painful decisions about long-term debt control, discretionary expenditures such as those on NLM have been beneficial to many people, not to mention the health of Americans and others around the world. When politicians and policy makers are deliberating, I hope they will consider the value and impact that government agencies like the NLM have made to so many people. I will always be grateful for what the NLM has done for me.

Public Rollout of the ONC Health IT Curriculum

2011-06-24T04:11:00.000-07:00

This week was a major milestone for the Office of the National Coordinator for Health IT (ONC) Health IT Curriculum project. The curricular materials that were developed for the 82 community college programs to rapidly expand the health IT workforce were released to all educators and the public at large. In this posting, I will provide the context for this project and describe what it is not before delving into the details of what the curriculum contains.

The ONC Health IT Curriculum is one of four programs in the overall ONC Workforce Development Program. The overall program was specified by Section 3016 of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the portion of the American Recovery and Reinvestment Act (ARRA), also known as the federal stimulus bill. ONC operationalized the program by designating 12 workforce roles, with six to be educated in the six-month community college programs and six to be educated in 1-2 year programs in universities. The primary audience for the curricular materials are the community college programs.

Five universities were funded under the $10 million project as Curriculum Development Centers: Oregon Health & Science University (OHSU), Columbia University, Duke University, Johns Hopkins University, and University of Alabama-Birmingham. Each center prepared four components each. One university, OHSU, was additionally funded to serve as the National Training & Dissemination Center (NTDC), given the additional tasks of developing the dissemination Web site, training community college faculty in use of the materials, capturing feedback, and providing technical support. The curricular materials are now available for download by the public on the NTDC Web site, although the feedback and support functions are limited to the 82 community colleges.

The curricular materials are not a certificate or degree program out of the box. Rather, the content should be thought of more like a library (or, to use the words of ONC Chief Science Officer Charles Friedman, PhD, a "buffet") from which educators can pick and choose content for their courses. The materials alone will not substitute for formal education, as good education still requires teachers, mentors, and fellow learners with whom to interact (whether in-person or on-line). However, the matierlals will be a valuable resource for a wide variety of educational activities in health IT. As the director of a graduate program in biomedical informatics, I know that OHSU will adopt some of these materials in its own graduate-level educational program (just as some of the curricular content came from our existing program).

The curricular materials consist of 20 components, each of which is comparable in depth to a college course. The components are subdivided into 8-12 units, each of which contain a variety of activities appropriate to the topic, including voice-over-Powerpoint narrated lectures, references, suggested readings, exercises, and more. The topic areas of the components are:

Introduction to Health Care and Public Health in the U.S.
The Culture of Health Care
Terminology in Health Care and Public Health Settings
Introduction to Information and Computer Science
History of Health Information Technology in the U.S.
Health Management Information Systems
Working with Health IT Systems
Installation and Maintenance of Health IT Systems
Networking and Health Information Exchange
Fundamentals of Health Workflow Process Analysis & Redesign
Configuring EHRs
Quality Improvement
Public Health IT
Special Topics Course on Vendor-Specific Systems
Usability and Human Factors
Professionalism/Customer Service in the Health Environment
Working in Teams
Planning, Management and Leadership for Health IT
Introduction to Project Management
Training and Instructional Design

ONC and the Curriculum Development Centers also developed a “set table” consisting of a matrix of curriculum components and workforce roles to guide community college programs in using components to train for particular workforce roles. The matrix specified the core set of components for each workforce role for two types of student backgrounds, healthcare and information technology.
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Each component also contains a blueprint document that provides an overview of the learning objectives and content for each unit. All of the components also have an instructor's manual that provides more detailed information, including listing of authorship and teaching information. The full set of blueprints have been rolled into a single PDF portfolio and are available on the ONC Web site.

Three of the components are "lab" components that make use of an educational version of the Veteran's Administration (VA) VistA EHR. A version of VistA that runs under various versions of Microsoft Windows is provided on the Web site, courtesy of the VA. However, this version will not be usable by everyone, as it requires a license for the Intersystems Cache environment, which is freely available to academic institutions but not others. Nonetheless, the materials will still be valuable to others who can adapt the exercises for other EHR systems.

All told, the curricular materials are a comprehensive resource. The entire collection of material is 7.5 gigabytes in size (6.75 gigabytes compressed) in 12,339 files. The 20 components contain 213 units, 460 lectures (some units have more than one lecture), 8913 slides, and 125.9 hours of lecture audio. In the collection are 460 Powerpoint files, 460 MP3 files, 465 PDF files, and 1346 Microsoft Word files.

We call this publicly available version of the curricular materials Version 2. It has been available to the ONC Community College Consortium for two months, and supersedes the original Version 1 provided to consortium members last year. The materials are distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. This means that all users of the curriculum can use, share, and adapt the materials but must attribute the originator of work, use the materials only for non-commercial purposes, and share any changes made under same license. Per the ONC, universities own the intellectual property for their components.

The support for the public rollout of the curricular materials will be minimal. This is in part because the funding does not have the resources to provide that support but also because these materials are aimed at educators who will adapt them into their own courses and other educational activities.

Another program in the ONC Workforce Development Program related to the project is the Competency Examination, a project led by Northern Virginia Community College. There are six exams, with one for each of the six community college-trained workforce roles. Each exam consists of 125 multiple-choice questions, to be taken in three hours and graded on a pass-fail basis. At least 80% of exam questions come from the curriculum components. Beta versions of the six exams became available on May 20, 2011, with the final versions to be ready in September. The exam is free to consortia member college graduates through their schools.

The final program in the is the University-Based Training (UBT) program, which funds training in the other six workforce roles deemed to require longer training at the university level. Nine universities or consortia thereof, including OHSU, were funded under this program. As noted elsewhere, OHSU recently had its first graduates from its UBT program, with many more in the pipeline.

The Curriculum Development Centers and ONC do not plan to rest on our laurels. We know there are many areas where Version 2 can be improved, and fortunately the two-year project includes additional funding to provide for a Version 3 that will be delivered in 2012. A planning process is underway to improve the content and technical aspects of Version 2, along with reducing its gap and overlaps.

It has been gratifying to be part of this project, which has consumed a great deal of my life since the project began in April, 2010. I have enjoyed all of the roles I have played, as Director of the NTDC, Director of the OHSU Curriculum Development Center, and author of several units. I will look forward to feedback about Version 2 and suggestions for enhancements in Version 3. How to sustain the curriculum once the ONC funding ends is also a key concern.

Informatics Destination: Buenos Aires

2011-06-21T04:08:00.000-07:00

I spent part of last week with my friends and colleagues at Hospital Italiano de Buenos Aires (HIBA) in Argentina. The HIBA Department of Health Informatics is truly an international leader in the field, with an internally developed electronic health record (EHR) that serves the needs of the hospital's clinicians, patients, and researchers. HIBA is a large academic medical center in the heart of Buenos Aires and also has a large health maintenance organization (HMO), Plan de Salud, that serves nearly half a million people. It also has a young but growing university.

The HIBA EHR has been in development for over a decade. At a time when the "conventional wisdom" of informatics is to acquire and implement commercial systems, HIBA has built a system tailored to its organization and workflow. Their success is a testament to the vision and leadership of the program's founder, Fernan Gonzalez Bernaldo de Quiros, MD. Dr. Quiros started HIBA's Department of Medical Informatics a decade ago to provide leadership in developing and implement the system, called ITALICA. He has now assumed the role of Vice President for Strategic Planning of HIBA, while Daniel Luna, MD has stepped in to head the department. Now called the Department of Health Informatics, they oversee all aspects of IT at HIBA, including non-clinical applications. An excellent overview of all their work is provided in a Yearbook of Medical Informatics 2009 article: Quiros, F., Luna, D., et al. (2009). Experience in the Development of an In-house Health Information System and the Training Needs of the Human Resources at the Hospital Italiano de Buenos Aires, 147-152, in Geissbuhler, A. and Kulikowski, C., eds. IMIA Yearbook of Medical Informatics 2009. Stuttgart, Germany. Schattauer.

HIBA has also become an international leader in informatics education and training. When the department was established, they also launched a medical informatics residency program. This program has trained the human resources necessary for the success of ITALICA. An emerging leader in the educational program has been Paula Otero, MD.

I first met Dr. Otero in 2004. A year later, she enrolled in the very first offering of the OHSU-AMIA 10x10 course. After the course ended, she proposed to translate the course into Spanish to make it available to a Latin America audience. She and her team successfully translated the course and began offering it across Latin America. While the first version was mostly a direct translation, the course has since diverged from the US-based course to be more specific to health care in Latin America. (For example, very little HIPAA!) For more information, see: Otero, P., Hersh, W., et al. (2010). A medical informatics distance-learning course for Latin America - translation, implementation and evaluation. Methods of Information in Medicine, 49: 310-315.

This initial collaboration set the stage for other collaborative activities. Dr. Otero, Dr. Quiros, and I were involved in the Rockefeller Foundation workshop devoted to building human capacity in health informatics in the developing world in Bellagio, Italy in 2008. We subsequently worked together on the AMIA Global Partnership Program. Dr. Otero has become my Co-Chair in leading the International Medical Informatics Association (IMIA) Working Group on Education.

The crowning achievement of our collaboration was the awarding of a grant from Fogarty International Center of the US National Institutes of Health (NIH). In 2009, we were awarded one of eight grants in Fogarty's Informatics Training for Global Health (ITGH) Program. The stated goal of our project under this funding was to extend our collaboration that had mostly been in clinical informatics into clinical research informatics. HIBA has a strong Institute of Basic Sciences and Experimental Medicine, which includes 31 basic research teams. Many are funded by grants, including some from the NIH.

We proposed in the grant, and have operationalized in the first two-plus years of the project, a plan for short-term, intermediate-term, and long-term training. The short-term training has been focused on clinical researchers, extending the Spanish 10x10 course with modules that teach them how informatics can augment clinical research.

The intermediate training has been more focused on informatics trainees, with a course in clinical research informatics developed by OHSU informatics faculty Judith Logan, MD, MS. This course was taught on-line in OHSU's spring academic quarter to both OHSU and HIBA informatics trainees. Dr. Logan also came on this trip to have an in-person meeting with the HIBA students.

The long-term training has focused on providing postdoctoral fellowship training to HIBA informaticians. At OHSU, we have treated these trainees as if they were fellows on our National Library of Medicine (NLM) training grant. The first two fellows - Damian Borbolla, MD and Vanina Taliercio, MD - have been at OHSU for over a year. A third fellow, Sonia Benitez, MD, will join them later this year. The goal for these trainees is for them to return to Argentina after their training to assume leadership roles in informatics and clinical research.

Dr. Logan and I also had the opportunity to give talks at HIBA (with more details and even an Elluminate recording of the slides and audio). Not only were there about 80 people present in person, another 25 or so listened in via Webcast. Some of the Webcast listeners even asked questions of the speakers. In my talk I provided an overview of the HITECH program for EHR adoption in the US. Dr. Otero translated my slides to Spanish and both the English and Spanish versions, with references, are available on my Web site. An interesting piece of trivia I learned on this trip is that the phrase meaningful use has no direct translation in Spanish. The closest translation is uso significativo. (Which is somewhat ironic, since HIBA is much closer to meaningful use of EHRs than most US hospitals!)

Although we have made substantial progress in our collaboration, the best is yet to come. We will look forward not to our trainees applying their new knowledge and skills to advancing healthcare and clinical research in Argentina, but also to new undertakings, such as a possible jointly developed master's degree.

Commencement Address Representing OHSU School of Medicine Graduate Studies Program

2011-06-06T07:38:00.000-07:00

The Commencement & Hooding Ceremony of the OHSU School of Medicine, also known as Graduation, is always an enjoyable time for me. It is gratifying to see another year's class of graduates from our Biomedical Informatics Graduate Program receive their hoods and diplomas. This year we had largest graduating class ever, with six PhDs, 12 students in our two master's programs, and 20 Graduate Certificates. This brings our total number of degrees and certificates awarded up to 336 since the inception of the program in 1996. This commencement we more than doubled our number of PhD graduates (from five to 11), and also saw the first group of graduates from our ONC University-Based Training (UBT) Program.

This year I also was invited to give the Graduate Studies Program faculty address. I was honored to represent the faculty of all of the OHSU School of Medicine graduate programs and share my informatics-tinged wisdom and vision with the larger School of Medicine audience.

Below is the text of my remarks delivered on Monday, June 6, 2011:

After all these years of sitting down in the faculty section of this ceremony, I am honored to be asked to give this address representing the faculty in the graduate programs of the School of Medicine. As some of you know, I direct the graduate program in biomedical informatics, which is the field devoted to the use of data and information, usually but not always aided by computers, to improve personal health, clinical practice, biomedical research, and public health. Like all disciplines, biomedical informatics has a science and methodology that is carried out by its researchers and practitioners, and a new group of graduates are entering the field by completing their studies today.

As the faculty in my program know, Commencement is a very important event for me. With the exception of last year due to an unavoidable conflict, I have attended every Commencement since our biomedical informatics graduate program had its first graduates in 1998. We began with a handful of Master's degrees, but now as of this graduation have over 300 alumni who have attained not only Master's degrees, but also PhDs and Graduate Certificates. Despite 13 years of graduating students, my thrill of seeing graduates of our program has not worn off. I am sure that my fellow graduate program directors feel the same way.

So what advice can I give to those who are graduating with PhDs, Master's degrees, and Certificates in the School of Medicine? I will skip the usual advice, important as it is, to devote your life's work to your profession, to keep a healthy balance of activities outside of work with family and friends, and to act professionally in a world of instant gratification and 24/7 information flow. Instead, I will try to provide some perspective and wisdom from my discipline of biomedical informatics.

I probably do not need to tell graduates, faculty, or even members of the audience that the 21st century is a golden era at the intersection of health sciences with information and computer sciences. It is truly changing what we do as clinicians, researchers, and other professionals who deal with health.

One of the best statements of this vision comes the Institute of Medicine and is the notion of the learning health system. We now truly have the ability to track and measure what we do in health care practice and public health, and drive research questions and answers from it. Our substantial federal investment in electronic health records, along with the growing ability to sequence genes, measure their expression, and analyze the products they produce, is ushering in an unprecedented era to compare and then learn the best approaches not only to treating disease but also keeping us healthy.

It is also critical to remember that no matter from what discipline you are graduating, success in this new era will require skills to use and manage information in ways that did not exist even a decade ago. You must understand the meaning and the limitations that exist with the increasing types and volume of data you collect. You must adhere to data standards so others can build on your work. Those of you working with human data also cannot forget the importance of protecting the privacy of individuals who have graciously permitted you to borrow their data for your work. In addition to skills in managing data, you must also be an expert in searching and accessing the literature and other scientific resources of your field. As if that is not enough, critical thinking and analysis are essential to all of this voluminous amount of data and information.

Another critical challenge to emerge in the 21st century is the need to collaborate across disciplines. The truly vexing problems of health care and public health require an interdisciplinary approach. Basic scientists, clinicians, informaticians, and others must come together to translate basic science into clinical care, to bring the best clinical care to the entire population, and insure that care is delivered with the highest quality and safety. We also need to reform our health care system to provide incentive for coordination and efficiency, not only because it will cost less but also because it will result in better patient outcomes. This will in turn require critical investments in information systems to bring the right information to the right people at the right time.

In closing, no matter what graduate degree or certificate you are receiving today, there are unprecedented opportunities. There may be uncertainties about health care reform, federal research funding, and the economy in general. But there is now unprecedented opportunity to impact health. I wish all graduates here today the best as they embark on their new careers.

(Postscript: The text of this talk also appears on the OHSU School of Medicine Commencement 2011 site.)

An Informatics Silver Lining to a Terrible Tragedy

2011-06-05T07:54:00.000-07:00

Although the tornado in Joplin, Missouri was a terrible and unfortunate tragedy, there is an interesting little side story related to biomedical informatics. I don't want to make light of the tragedy, particularly the town having its hospital destroyed. However, an article on the St. Louis Today web site tells an interesting sidebar.

Apparently the destroyed hospital made its conversion to electronic health records (EHRs) just three weeks before the tornado. The EHR system did not miss a beat, and remained running during and after the storm. As such, people needing their records accessed were able to have that done when they obtained medical care elsewhere.

This situation brings memories of Hurricane Katrina, where just about all of the hospitals in New Orleans had their medical records rooms, typically in the basements of their facilities, destroyed by the ensuing flooding. The one exception was the New Orleans VA Medical Center, which was able to keep its records intact through the well-known VA EHR system.

Joplin also did have a health information security breach from the tornado. Although unlike most breaches we read about lately, this breach was purely due to non-electronic records, in particular paper records and x-ray films being blown up to 75 miles away.

This story does not alleviate the terrible tragedy of the tornado, nor does it rebut any of the serious challenges to implementing EHRs. It does, however, show one example of the value of electronic data systems in healthcare.

Update on the ONC Curriculum Development Centers Program

2011-05-26T01:52:00.000-07:00

I recently posted an update about one of our Office of the National Coordinator for Health Information Technology (ONC) projects, the Oregon Health & Science University (OHSU) offering of the ONC University-Based Training (UBT) program, and promised an update to follow on our other grant, the Curriculum Development Centers program. The latter is a $10 million program for five universities – Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University (OHSU), and University of Alabama-Birmingham – to develop curricular materials for the 82 community colleges delivering short-term training for six of the 12 ONC-defined workforce roles. One university, OHSU, was provided additional funding to serve as the National Training & Dissemination Center (NTDC) that is additionally tasked with developing a Web site for dissemination of the materials, training community college faculty in their use, and capturing and distributing feedback collected from community college faculty.

As with the UBT program, the Curriculum Development Centers have been funded since April, 2010. Since that time, substantial progress has been made. The first version of the curriculum was delivered to the community colleges in two halves, one in August, 2010 and the other in October, 2010. Because of the tight timeline of the curriculum deliverables and the start-up of the community college programs, it was decided to not disseminate Version 1 beyond the five community college consortia overseeing the 82 member colleges. This also led to the decision for Version 2 to be delivered relatively quickly, in the spring of 2011, and mainly be an incremental update focused on improving the clarity and technical quality without making any major content overhaul. It was also decided that Version 2 would be the release promised in the original Request for Proposals (RFP) to be made available to all institutions of higher learning, which for all practical purposes means the general public. This public roll-out will take place in the summer of 2011.

Recall that the community college short-term training programs are focused on six of the 12 workforce roles that ONC has deemed necessary to help eligible professionals and hospitals achieve meaningful use of the electronic health record (EHR). (The other six workforce roles are trained by the UBT program.) Each of the 82 community colleges can offer certificates in one to six of the workforce roles, while the consortium to which it belongs must offer all six across their region.

The curriculum consists of 20 components, each of which is comparable to a college-level course (which of course can vary widely based on the length, depth of material, background of students, and other factors). The components are not called courses because it is up to the community colleges to turn them into actual courses in their programs. The colleges can use the materials “out of the box,” with little or no modification, or they may modify them as they desire for the needs of their programs.

ONC and the Curriculum Development Centers also developed a “set table” consisting of a matrix of curriculum components and workforce roles to guide community college programs in using components to train for particular workforce roles. The matrix specified the core set of components for each workforce role for two types of student backgrounds, healthcare and information technology.

Each component has a “blueprint,” which provides learning objectives and a detailed overview of the content. Each component is broken down into 8-15 units, which correspond roughly (though variably) to one week of a course. Each unit typically consists of learning objectives, a narrated slide lecture (delivered as Powerpoint slides, MP3 audio files, and narrated voice-over-Powerpoint Flash files), references, exercises, and other materials. (The blueprint for Version 1 on the ONC Web site will soon be replaced by the one for Version 2.)

The topic areas of the components are:

Introduction to Health Care and Public Health in the U.S.
The Culture of Health Care
Terminology in Health Care and Public Health Settings
Introduction to Information and Computer Science
History of Health Information Technology in the U.S.
Health Management Information Systems
Working with Health IT Systems*
Installation and Maintenance of Health IT Systems*
Networking and Health Information Exchange
Fundamentals of Health Workflow Process Analysis & Redesign
Configuring EHRs*
Quality Improvement
Public Health IT
Special Topics Course on Vendor-Specific Systems
Usability and Human Factors
Professionalism/Customer Service in the Health Environment
Working in Teams
Planning, Management and Leadership for Health IT
Introduction to Project Management
Training and Instructional Design

Components 7, 8, and 11, denoted with an asterisk* above, are “lab” components that provide hands-on instruction. These components make use of a fully functioning version of the Veteran’s Administration VistA EHR that is included with the curricular materials and can be installed under most flavors of Windows (as well as some Windows virtual machines that run under MacOS and Linux).

Another program in the ONC Workforce Development Program related to the project is the Competency Examination, a project led by Northern Virginia Community College. There are six exams, with one for each of the six community college-trained workforce roles. Each exam consists of 125 multiple-choice questions, to be taken in three hours and graded on a pass-fail basis. At least 80% of exam questions come from the curriculum components. Beta versions of the six exams became available on May 20, 2011, with the final versions to be ready in September. The exam is free to consortia member college graduates through their schools.

As noted above, Version 2 will be released to all institutions of higher education in July, 2011. The details of how to access the materials will be provided at that time. For this release, the Curriculium Development Centers adopted a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. This means all users of the curriculum can use, share, and adapt the materials but must attribute originator of work, use the materials only for non-commercial purposes, and share any changes made under same license. Per the original RFA, universities own the intellectual property for their components.

The Curriculum Development Centers have also started planning for the third and final version that will likely be released in early 2012. Planning for this version is underway. Unfortunately, there is not now any plans for continued funding, at least by ONC, beyond the project end in April, 2012. It is conceivable that some sort of open-source approach could be adopted to keep the curriculum going, but I do not see the resource continuing to be viable without some investment, at least in its infrastructure. Nonetheless, I am pleased overall with the project and I believe it will be an enduring contribution to the biomedical and health informatics community. I am looking forward to Version 3 and whatever opportunities there are to continue the project beyond it.

Physician Certification in Informatics

2011-05-23T19:31:00.000-07:00

I am frequently asked about the status of certification of physicians in informatics. I did touch on this topic briefly in my posting on informatics opportunities for physicians last fall, but let me address the question of certification in more detail in this posting.

The motivation for physician certification in informatics is to recognize the growing stature and need for professional expertise of physicians who spend a significant amount of their time performing informatics-related duties. This includes not only the growing role of the Chief Medical Informatics Officer (CMIO), but other jobs where a physician draws on his or her expertise at the intersection of medicine and informatics.

The "gold standard" for any type of certification of physicians is board certification. There are currently 24 specialty boards (e.g., internal medicine, family medicine, pediatrics, surgery, radiology, preventive medicine, etc.), most of which have subspecialty boards as well (e.g., cardiology, hematology/oncology, and general internal medicine in internal medicine). Some subspecialties, such as geriatrics and palliative medicine, are offered by more than one specialty board. This will be the model for the clinical informatics subspecialty, and in fact the goal will be for it to be offered by all 24 specialty boards.

A comprehensive overview of the rationale and plan for developing the clinical informatics subspecialty was published in early 2010 by Detmer et al. [1]. This paper described the development of medical specialties and subspecialties generally and in the context of the new proposed subspecialty of clinical informatics. A more recent overview of the status board specialties was published last year and included mention of the proposed one for clinical informatics [2].

The proposal to establish the clinical informatics subspecialty was developed by the American Medical Informatics Association (AMIA) and submitted to the ABMS in 2010. The lead board submitting the proposal was the American Board of Preventive Medicine (ABPM), which has since been joined by the American Board of Pathology. The proposal had its first "reading" in early 2011, with a second reading and possible vote coming in September, 2011.

Certification in clinical informatics will work like any other multi-board subspecialty. To become certified, a physician will need to meet certain training requirements and then pass a certification exam. In the early years (usually the first five years of a specialty's existence), those with a certain level of experience will be able to "grandfather" in on the training requirements in a "practice track" and certify by passing the exam only. Those training after the initial practice track period will be required to complete some sort of fellowship in the specialty. The practice track requirements for clinical informatics will be determined after the ABMS approves the subspecialty and will likely apply to those with some defined level of time and depth of experience in clinical informatics settings.

If the ABMS proposal is approved, the ABPM will begin development of a certification exam, which will likely become available in the fall of 2012 for those meeting the practice track requirements. The next step will be to define the requirements for clinical fellowships in clinical informatics and their accreditation by the Accreditation Committee for Graduate Medical Education (ACGME), which accredits residency and specialty fellowship training programs.

Papers published in JAMIA in 2009 laid out the details of the core curriculum [3] and training requirements [4] for the subspecialty. These were developed over a two-year process, funded by a grant to AMIA in 2007 from the Robert Wood Johnson Foundation. Two task forces were convened to address the core curriculum and training requirements. (I was a member of the latter.) These task forces led to the ABMS proposal that is currently under review.

Even though the process for establishing the subspecialty is well-defined, a number of questions remain. One question is how many healthcare organizations and others will require their physician-informatician practitioners to be certified. Another question, very critical to academic informatics units, is what will be the role for formal didactic education, especially that offered by distance learning. Programs such as ours at OHSU have been a popular vehicle for physicians and others to become informatics practitioners. The distance learning aspect has been especially valuable, as many clinicians enter informatics careers after they have established their clinical careers. The graduate-level education approach has been validated by the strong uptake of these programs as well as the more recent funding for them though the Office of National Coordinator for Health Information Technology (ONC) University-Based Training (UBT) Program, including the OHSU offering. I am hopeful that ACGME will adopt flexibility in the clinical informatics fellowship program educational programs, including possibly allowing organizations like OHSU to provide the coursework portion of the training requirements in settings where a large educational infrastructure is not available.

Professional recognition is important for any discipline, especially within medicine. This includes the growing number of informatics practitioners. Within medicine, the best approach to professional recognition is formal board certification. To that end, I look forward to seeing the specialty approach develop and thrive. As I am personally still board-certified in internal medicine, I hope to be able to become subcertified in clinical informatics myself.

References

[1] Detmer, D., Munger, B., et al. (2010). Clinical informatics board certification: history, current status, and predicted impact on the medical informatics workforce. Applied Clinical Informatics, 1: 11-18.
[2] Cassel, C. and Reuben, D. (2011). Specialization, subspecialization, and subsubspecialization in internal medicine. New England Journal of Medicine, 364: 1169-1173.
[3] Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 153-157.
[4] Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 158-166.

First Year of the OHSU University-Based Training (UBT) Program

2011-05-06T14:04:00.000-07:00

It has been a little over a year since Oregon Health & Science University (OHSU) was awarded two grants from the Office of the National Coordinator for Health IT (ONC) Workforce Development Program. Activity on these projects has been a major part of the work in our department, and certainly of my time, over this period. In this posting, I will report on our University-Based Training (UBT) Program. In a later posting, I will report on our work on the other funded project, the Curriculum Development Centers/National Training & Dissemination Center Program.

OHSU was one of nine universities (or consortia thereof) awarded a UBT grant. We have met all of our goals and timelines so far for the project. The gist of our funded proposal was to enroll students into our Graduate Certificate and Master of Biomedical Informatics (MBI) programs, with additional course requirements based on the specific ONC workforce roles. As OHSU is on an academic quarter system, Graduate Certificate (classified by ONC as Type 1) students are expected to complete the program in an accelerated part-time status in four quarters (one year) while MBI (classified by OC as Type 2) students are expected to complete the Master's program in six quarters (one and a half years) as full-time students. We were awarded $3.08 million to fund 135 Type 1 and 13 Type 2 students over three years through 2013. The "ad" on this page links to the Web page describing the program.

We accepted 12 Type 1 students to start in the summer quarter of 2010, with 11 of those students expected to graduate in June, 2011, along with two additional students who completed the program in an accelerated manner. We will also have one Type 2 student graduating in June, 2011. These 14 graduates will be eligible (and encouraged!) to attend the OHSU June 6, 2011 Commencement.

We have an additional 74 Type 1 students in the pipeline who started the program in the fall (34), winter (26), and spring (14) quarters. These students, along with eight Master's students, are for the most part on track to graduate on time.

The students we have accepted have a great deal of geographic and occupational diversity. Similar to our distance learning program in general, our UBT students reside all across the United States. (We actually have distance learning students living in 40 states as well as six countries.) Our UBT students reside in 20 different states, with some over-representation in our region, probably reflecting proportions of applicants. Those states with more than one student in our UBT program include:

Oregon - 39 (49%)
Washington - 7 (9%)
California - 4 (5%)
New York - 4 (5%)
Texas - 3 (4%)
Maryland - 3 (4%)
Tennessee - 2 (3%)
Utah - 2 (3%)
Virginia - 2 (3%)
Minnesota - 2 (3%)
Wisconsin - 2 (3%)

Our students also come from many diverse career backgrounds. While the majority come from healthcare fields, a decent-sized minority do not, and some have highly technical backgrounds who are coming to learn how information technology is applied in healthcare settings. The backgrounds with more than one representative include:

Medicine (Physician) - 16 (20%)
Nursing - 13 (16%)
Business/Management - 10 (13%)
Liberal Arts/Humanities - 6 (8%)
Computer Science - 6 (8%)
Public Health - 4 (5%)
Biochemistry/Biology/Chemistry - 4 (5%)
Finance/Accounting - 2 (3%)
Health Information Mgmt - 2 (3%)
Healthcare Management/Administration - 2 (3%)

Our students also have a variety of highest degrees, with over half having a graduate-level degree already. The distribution of highest degrees is as follows:

Bachelors - 34 (44.1%)
Masters - 24 (31.1%)
MD - 16 (20.8%)
PhD - 3 (3.9%)
Other healthcare doctorate - 1 (1.3%)

One of the challenges we have faced is the competitive admissions process. We have had many more qualified applicants than we have funded positions for, so we have not been to fund some highly qualified applicants. The rate of acceptance has been 34 out of 162 (21.0%) for the fall, 26 out of 102 (25.5%) for the winter, and 14 out of 73 (19.2%) for the spring.

Moving forward, we are on track to have an additional 34 Type 1 graduates at the end of the summer quarter in early September, 2011. On September 9-10, OHSU plans to hold an informatics program reunion event, celebrating the 15 year anniversary of our first informatics degree program and the first graduates of our UBT program. Additional students will graduate later this year and into 2012, including our initial cohort of MBI students.

All told, we have committed 78 of our 135 (57.8%) Type 1 slots and eight of our 13 (61.5%) Type 2 slots. We are taking the summer quarter off for new admissions and will be admitting Type 1 and Type 2 students starting again in the fall quarter. We will award the rest of our funded slots during the 2011-2012 academic year, aiming to have everyone complete the program by the end of grant in April, 2013. During this time, our existing program is still operational, and those not awarded UBT funding can still enroll as self-funded students.

We have also implemented practicum (for Graduate Certificate students) and internship (for Master's students) programs . These programs are being administered by an Internship Coordinator whom we have hired. Students are required to find their own practicum or internship, although we help them however we can. The hosting organizations so far include health care organizations, regional extension centers, and vendors.

Another hire is our career counselor, who will help students identify and apply for jobs. We also hope this individual will collaborate with the internship coordinator as well as lay the foundation for continued relationships with employers beyond the end of the UBT funding.

All told, we are pleased with what we have accomplished in the ONC UBT program. We hope this will lead to a sustainable increased interest in biomedical informatics education and careers beyond the end of the grant itself.

Professional Science Masters: The Direction for Masters-Level Professional Degrees in Informatics?

2011-05-04T09:40:00.000-07:00

This week, the Department of Medical Informatics & Clinical Epidemiology (DMICE) of Oregon Health & Science University (OHSU) is hosting a regional workshop focused on Professional Science Masters (PSM) degrees and programs. While attendees will come from across the Pacific Northwest, the Oregon University System (OUS) is moving forward with development of a statewide program. We are interested in exploring whether our Master of Biomedical Informatics (MBI) might fit the bill to transform into a PSM. For more information on what a PSM is, see their Web site.

PSM programs are professional science degrees with three additional attributes:

"Plus" courses that provide the student skills for working in industry settings, such as business and management, writing and communications, and others
A rigorous internship program that replaces the traditional master's thesis or capstone
Guidance by an external advisory committee from industry that oversee the curriculum and/or participate in the internship program

DMICE offers graduate-level programs in the field of biomedical informatics. Although we are not formally a PSM, our existing programs, especially our MBI degree, have many of the attributes required of a PSM, namely the "plus" courses, an internship program, and an external advisory committee. We changed an MBI program requirement last year that allows a structured internship to be acceptable as the program capstone.

We were actually exploring the PSM option when the large amount of funding from American Recovery & Reinvestment Act (ARRA) for investment in health information technology came along and sidetracked these efforts. Of course, our Office of the National Coordinator for Health IT (ONC) University-Based Training (UBT) grant has many conceptual overlaps with the PSM concept, with its goal of producing informatics professionals who will develop, implement, and lead electronic health record (EHR) adoption in healthcare settings.

Of course, our informatics program is focused on more than EHR adoption, even though that is the largest need. But there are plenty of other critical needs for informatics in health and biomedicine, including in genomics, clinical and translational research, public health, consumer health, and even other clinical applications, such as telemedicine. As the UBT program reaches a steady state, and with it winding down in 2013, we are now reconsidering again the transformation of the program to an official PSM. This week's workshop will help inform our next steps.

Overview of the OHSU Biomedical Informatics Program

2011-05-01T07:17:00.000-07:00

People sometimes ask me for a big picture overview of all the programs available in the Biomedical Informatics Graduate Program in the Department of Medical Informatics & Clinical Epidemiology (DMICE) at Oregon Health & Science University (OHSU). I provide that in this posting.

Biomedical informatics is the field that uses information and related technologies to advance individual health, healthcare, public health, and biomedical research. Students enter with a variety of backgrounds and upon graduation take jobs in a diverse array of settings, including healthcare organizations, industry, research labs, and public health agencies. The OHSU program has offerings along many dimensions.

One dimension is the degree/certificate type:

Doctor of Philosophy (PhD) in Biomedical Informatics
Master of Science (MS) in Biomedical Informatics
Master of Biomedical Informatics (MBI)
Graduate Certificate (GC) in Biomedical Informatics

A second dimension is the program track:

Clinical Informatics (CI) - focus on health care, individual health, and public health
Bioinformatics and Computational Biology (BCB) - focus on computational aspects of genomics and molecular biology, especially their relation to human health
Health Information Management (HIM) - focus on Registered Health Information Administrator (RHIA) certification

A third dimension is whether the program is on-campus (oc) or on-line (ol), although the two can be co-mingled, especially by local students in the Portland area. The GC program can be done completely on-line, while the MBI program done on-line requires the student to take two on-campus "short" (one week) courses.

The following table shows the degree/certificate and track dimensions, with each cell indicating whether or not the program is offered on-campus or on-line.

Track Degree	CI	BCB	HIM
PhD	oc	oc
MS	oc	oc	oc
MBI	oc/ol	oc	oc/ol
GC	oc/ol		oc/ol

Where does the 10x10 ("ten by ten") program fit into this? The 10x10 curriculum is essentially equivalent to the introductory course (BMI 510) in the CI and HIM tracks.

More information is available on our program Web site: http://www.ohsu.edu/informatics/

Information Retrieval (Search) in Health and Biomedicine Still "Springs" Eternal

2011-04-21T23:03:00.000-07:00

One of my earliest visions of computers in medicine was the ability to type in a question and get an answer. In 1980s, while everyone in informatics was trying to build expert systems, I followed a different dream, of being able to find clinical information seamlessly. In that decade, however, I never could have imagined being able to pull up something called a Web browser, typing in words, and getting back "pages." Especially as I can do now, with something that fits in my pocket, also makes phone calls, and is connected to something I had not yet heard of in the 1980s (before I started my informatics training) called the Internet.

This fascination guided my early research interests in the area of information retrieval. I write about it now because every spring I teach my course on this topic in the OHSU graduate program, BMI 514/614. (Hence the title of this posting.) My interest in this area resulted in dozens of scientific papers and a textbook, currently in its third edition [1]. Despite the marvel I have for today's modern systems, I always have to ask myself, Why didn't I think of the idea of ranking the output (Web pages) by how many other pages pointed to them? Had I thought of that before a couple Stanford graduate students named Brin and Page, my life might be considerably different. Or at least my wealth!

I suppose one is getting up in the years when you marvel at how things are now relative to how you remember them. I certainly recall "searching" when I was in medical school in the 1980s, which involved thumbing through the giant Index Medicus books on long shelves in the library. You would "link" to the full text by walking to a different part of the library where the journals were. If your needs were really critical, you could call on a librarian for help, who would take your request to a special computer that accessed a database somewhere (which happened to be MEDLINE, from the National Library of Medicine).

I actually did my first on-line searching in the 1980s. I was able to access PaperChase, and later Elhill, through dial-up networks, though at a price. For an even heftier price, you could get access to the full text … at least "text" in monospaced font and no figures or images. The world did advance, and by 1998 you could search Pubmed for free. (Al Gore, who actually deserves more credit in this area than his critics deny him, did the first "free" search.)

Now, of course, searching is ubiquitous. You can't even not do it, since most browsers will throw you into a search engine when you type in an invalid Web address (URL) into your browser. And the world not only searches, but searches for health information. The two major periodic surveys of health information searching show that 80% of Internet users have searched for health information for themselves, their family, or their friends [2, 3].

Of course, like many areas of informatics, while use of systems is ubiquitous, not all of the problems of systems are solved. Indeed, a few years ago I wrote a short piece on this topic [4]. As wonderful as today's search systems are, we still have many areas for improvement. In that paper, I identified four areas where grand challenges remained:

Content - getting diverse users to the right information for the right task
Indexing - developing better metadata to get searchers to that proper content
Linkage - allowing navigation across multiple resources, even those of different publishing entities
Access - making access as open as possible but still being protective of intellectual property

Just as I could not fathom the World Wide Web in the 1980s, I wonder as I write this in 2011 what the world of search and on-line knowledge access will be a decade or two from now.

References

Hersh, W. (2009). Information Retrieval: A Health and Biomedical Perspective (3rd Edition). New York, NY. Springer.
Fox, S. (2011). Health topics. Washington, DC, Pew Internet & American Life Project. http://www.pewinternet.org/~/media//Files/Reports/2011/PIP_HealthTopics.pdf.
Taylor, H. (2010). "Cyberchondriacs" on the Rise? Those who go online for healthcare information continues to increase. Rochester, NY, Harris Interactive. http://www.harrisinteractive.com/vault/HI-Harris-Poll-Cyberchondriacs-2010-08-04.pdf.
4. Hersh, W. (2008). Ubiquitous but unfinished: grand challenges for information retrieval. Health Information and Libraries Journal, 25(Suppl 1): 90-93.

What is the Evidence Base for Informatics, Health IT, and Related Areas? Some Recent Analyses

2011-04-20T00:26:00.000-07:00

The first part of 2011 has brought a number of publications, and subsequent discussion, about the "evidence base" for the efficacy of biomedical and health informatics interventions, including electronic health records. These publications and conversations come against a backdrop of a very poisoned political environment in the United States, where everything about healthcare, including informatics, has become unfortunately very politicized. In this posting, however, I will stick to the science.

The first high-profile study of the year was the on-line posting of the Archives of Internal Medicine paper by Romano and Stafford [1], which I discussed in an earlier posting. The official publication of the paper, as well as letters about it, will be published in May, 2011.

Probably the next most high-profile study was the publication of an update of a systematic review of studies of outcomes from health information technology interventions by Buntin and colleagues [2]. This was actually the second update of an original systematic review that was published in 2006 by Chaudhry and associates [3], the first update of which was published by Goldzweig and colleagues in 2009 [4].

Systematic reviews are comprehensive reviews of all research evidence on a given area or question [5]. When studies are homogeneous enough (e.g., all studies assessing the treatment of hypertension to reduce cardiovascular disease), a mathematical technique known as meta-analysis can be performed to combine results across studies to achieve larger a sample size and more statistical power. But most areas, certainly so in informatics, have research questions too heterogeneous to enable use of meta-analysis. Nonetheless, studies can be categorized to look at general questions asked, such as efficacy of decision support to reduce medical error or access to data in a more timely manner to reduce cost of care.

The three successive systematic reviews [2-4] using relatively similar methodology have summarized outcomes of studies of health information technology (HIT) over particular time periods:

Chaudhry, 2006 – studies from 1995-2004 [3]
Goldzweig, 2009 – studies from 2004-2007 [4]
Buntin, 2011 – studies from 2007-2010 [2]

As with most systematic reviews, these captured a broad net of literature and reviewed it for quality of methodology and its results.

Chaudhry et al. identified 257 studies, with the most benefit shown for:

Adherence to guideline-based care
Enhanced surveillance and monitoring
Decreased medical errors

An interesting caveat of the results that the authors noted was that 25% of the identified studies came from four institutions (Partners Healthcare, Veteran's Administration, Indiana University/Regenstrief Institute, and Vanderbilt University) and there were few studies of commercial systems, raising concerns about generalizability.

In their update, Goldzweig et al. found 179 new studies. They noted comparable results to the study of Chaudhry et al., but also found an increased number of studies of patient-focused applications that ran external to EHR, e.g., Web-based care management. They note a small increase in the number of studies of commercial, off-the-shelf systems, though 20% of studies still came from the four leading institutions. They also found there was still a paucity of cost-benefit analyses.

In the new systematic review, Buntin et al. identified 154 new studies with 278 individual outcome measures. While acknowledging wide divergence of study quality and methodologies, not to mention outcomes studied, they noted that 96 (62%) of studies had positive improvement in one or more aspects of care, with 142 (92%) showing positive or mixed positive-negative outcomes. They found that the studies used quantitative and qualitative approaches, with those using statistical hypothesis testing more likely to have positive outcomes. They slightly redefined “health IT leader” institutions, but noted that a large number (28) still came from these institutions, but did decreased somewhat to 18% of the studies. Somewhat reassuring was that the “leader” studies did not differ in methods or results from the other studies.

Buntin et al. grouped the outcomes into seven categories, noting document improvement in all of them:

Access to care
Preventive care
Care process
Patient satisfaction
Provider satisfaction
Effectiveness of care
Efficiency of care

Another bit of evidence from early 2011 was a review of all eHealth systematic reviews took exception to direction and quality of evidence [6]. The authors note that many studies of eHealth, including clinical applications (i.e., health IT), had poor methodology, raising concern over validity of the results. The results echo those of a systematic review I led about telemedicine studies several years ago [7]. One concern about this new review is that its methodology of being a review of reviews might magnify poor evidence. But someone needs to reconcile this review with the one of Buntin et al. [2].

It should be noted that another line of thought has been critical of the experimental approach to evaluation of health IT. Two recent commentaries note that these approaches cannot capture the whole picture of a health IT intervention, especially ones that occur in real-world implementations in complex settings, like states or even whole countries [8, 9]. I acknowledge these criticisms, though would argue back that we should not view these approaches as either-or. There is hopefully plenty of room for all types of disciplined evaluation of informatics, with clinical trials and similar experiments

References

1. Romano, M. and Stafford, R. (2011). Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives of Internal Medicine, Epub ahead of print.
2. Buntin, M., Burke, M., et al. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs, 30: 464-471.
3. Goldzweig, C., Towfigh, A., et al. (2009). Costs and benefits of health information technology: new trends from the literature. Health Affairs, 28: w282-w293.
4. Chaudhry, B., Wang, J., et al. (2006). Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144: 742-752.
5. Anonymous (2011). Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC, Institute of Medicine.
6. Black, A., Car, J., et al. (2011). The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Medicine, 8(1): e1000387.
7. Hersh, W., Hickam, D., et al. (2006). Diagnosis, access, and outcomes: update of a systematic review on telemedicine services. Journal of Telemedicine & Telecare, 12(Supp 2): 3-31.
8. Greenhalgh, T. and Russell, J. (2010). Why do evaluations of eHealth programs fail? An alternative set of guiding principles. PLoS Medicine, 7(11): e1000360.
9. Patrick, J. (2011). The validity of personal experiences in evaluating HIT. Applied Clinical Informatics, 1: 462-465.

Looking Back, Moving Forward

2011-04-01T05:52:00.000-07:00

This week marks a year ago that I woke up (on the morning of Friday, April 2nd, to be precise) to find emails in my inbox telling me that Oregon Health & Science University (OHSU) had received our two awards from the Office of the National Coordinator for Health IT (ONC) Workforce Development Program. As most readers know, those programs are going well, and I am planning to provide my occasional updates of our efforts in the programs here in the coming weeks ahead. A succinct news report of the programs, for which I was interviewed, is available from the California Health Care Foundation (CHCF).

Another anniversary of sorts is for this blog, which has now been in existence a little over two years (since March 2, 2009, to be precise). I have enjoyed having this forum to share my thoughts about topics of interest and passion to me. I have tried to create thoughtful pieces that explore various issues, and not just brief streams of consciousness.

The year 2011 also is another anniversary year, which is the 15th year of informatics degree programs being offered by OHSU. In 1996, we opened the doors to our initial Master of Science degree. Of course, we have added a number of other degrees since then, such as our Master of Biomedical Informatics (non-thesis, professional master's), PhD, and Graduate Certificate. To celebrate the 15-year anniversary, as well as the first two groups of graduates from our ONC funding, we are planning to hold a celebration in September. The event will be open to the public and is scheduled to take place on September 9-10, 2011. All alumni, students, faculty, and friends of the program will be invited, with alumni being able to present about what they are currently doing, along with a number of other keynote speakers. (Save the date!)

Of course, we are not resting on our laurels, and are quite busy with our current work, the totality of which would be much longer than anyone would want to read. I am happy to announce that the 10x10 ("ten by ten") program continues going strong, with a number of new offerings planned to start in the next few months. One of the offerings is a general AMIA offering but the rest demonstrate the partnerships that we have built for specific offerings. As with all 10x10 courses, the offerings include the basic on-line portion of the course and an in-person session often associated with a professional meeting.

They include:

Regular AMIA offering aimed at all audiences, starting April 27, 2011 with in-person session at any AMIA national meeting in the next year. (Next meeting in Washington, DC, with in-person session on October 23, 2011)
Offering focused on dietitians and the area of nutrition informatics, in partnership with the American Dietetic Association (ADA), starting April 13, 2011, with the in-person session at the ADA meeting in San Diego, CA on September 24, 2011
Offering in Singapore in partnership with Gateway Consulting, starting May 2, 2011, with the in-person session in Singapore (!) on September 14, 2011
Offering focused on emergency physicians, in partnership with the American College of Emergency Physicians (ACEP), starting June 29, 2011, with the in-person at the ACEP meeting in San Francisco, CA on October 14, 2011

Honorable Mention

2011-03-30T04:32:00.000-07:00

Who should be the next National Coordinator for Health Information Technology (HIT), i.e., the Director of the Office of the National Coordinator for HIT (ONC)? My name appeared recently on a list of 24 individuals nominated as a potential replacement for the current National Coordinator, Dr. David Blumenthal, who is leaving the post next month to return to academia at Harvard University.

Well, the results of the voting are in, and I was flattered to finish fifth, capturing 5.6% of the 736 votes cast. The winner of the poll was Jessica Kahn, Technical Director for HIT for Medicaid at the Centers for Medicare and Medicaid Services. Following in a close second was Dr. Marc Chasin. Vice President and Chief Medical Informatics Officer at St. Luke's Health System in Boise, Idaho. I am delighted to report that Dr. Chasin is a former student of mine, having taken the 10x10 ("ten by ten") course.

I have to admit that I am ordinarily unswayed by magazine or Web polls that are completely unscientific and really just popularity contests. Still, I was flattered to be part of this. Perhaps, as they say in show business, any publicity is good publicity.

This all said, I don't think I will be leaving Oregon Health & Science University any time soon. I have waited my whole career for the situation I and the department I lead are currently in, seeing the maturation of our field and the resources now available to support education and research endeavors within it.

I also do not envy the person who actually replaces Dr. Blumenthal. Clearly the HITECH Act has, to use the terminology of Gartner Hype Cycle, hit its peak of expectations. Some of the programs are down in the trough of disillusionment, although I am confident that most if not all of them will eventually level off in the plateau of productivity. Given the current political state of Washington, DC, where scoring political points seems to have overtaken governing and producing value from government programs, the next National Coordinator is likely to spend a good deal of time in non-productive Congressional hearings. It's not that I don't think government bureaucrats, like everyone else, need to be held accountable, but it is unlikely the primary purpose of those hearings will be to report on the value to healthcare and economy that HITECH has wrought.

Being the optimist that I am, I am not dwelling too much on the current poisoned atmosphere in Washington, DC. I will certainly defend to anyone the productive investment that has been made the federal government in HIT. In our programs funded by educational grants, skills and leadership have been imparted on a new cadre of individuals, and the curricular materials we are producing will have a lasting impact on the primary goal of biomedical and health informatics, which is to improve human health, healthcare, biomedical research, and public health with information.

Natural Language Processing: A Dream That Won't Die … and Shouldn't

2011-03-10T15:02:00.000-08:00

One of the longest-standing dreams of informatics, dating back to the early (i.e, 1960s) era of artificial intelligence, is the use of natural language processing (NLP) to extract data about patients from clinical narrative data (e.g., progress notes, discharge summaries, etc.) in the electronic health record (EHR). The notion that you can take the narrative language of clinicians and turn it into concrete facts that can be used for clinical decision support, clinical research, quality measurement, surveillance, etc. is immensely appealing.

Alas, that dream, at least in a generalizable way, is still a dream. You can count a number of my published papers over the years as a few among the many valiant efforts. Unfortunately, the variability (or some might say mangling, especially by physicians) of language, along with the hidden context and meaning "between the lines," makes NLP a very difficult task to program in a computer.

Some, however, have managed to succeed in focused ways. For example, generalizable decision support also never succeeded but it has been found that focused decision support works quite well and is used in EHRs daily. Likewise, there have a number of focused areas where NLP has provided useful data for clinical processes.

It is in this context that I am pleased to report on another contribution to the literature of clinical NLP, which is a paper that appeared in a recent issue of the Journal of the American Medical Informatics Association (JAMIA) and is lead-authored by a former student, Mary Stanfill [1]. I am a co-author. It is always a thrill to see a student publish a peer-reviewed paper, especially one that started as a term paper in one of my courses, advanced to a capstone project in a master's degree, and ultimately ended up in one of the leading journals in our field.

This paper also makes a valuable contribution of being a systematic review of all studies that report results of "automated coding and classification." The analysis shows that there have been many efforts performed using many methods in a variety of clinical domains, with a wide range of results. Of course, this gets to a gripe I have had with clinical NLP and related text mining researchers over the years, which is that evaluation studies have not advanced much beyond measuring the accuracy (e.g., recall, precision, sensitivity, specificity, etc.) of how well systems identify concepts in the text [2]. I would prefer to see the next step in systems being evaluated, such as how well NLP can impact the tasks it might be used for, such as quality measurement programs or facilitating clinical research studies. This would be akin to the "task-oriented" studies of information retrieval systems I performed years ago, which focused on how well searchers completed tasks using retrieval systems rather than just measuring how many relevant articles they retrieved [3].

The good news is that systems using NLP are starting to be deployed in operational clinical settings or clinical and translational research programs, and there is an ever-increasing amount of real data in electronic form for them to use. In addition to a growing number of individual studies, there are also large-scale projects of which NLP is a significant part. There include:

Informatics for Integrating Biology and the Bedside (i2b2) - a long-standing project to facilitate the use of clinical data for genomic and clinical research. One of its activities includes a yearly challenge evaluation that allows research to compare systems and results on a common task. The i2b2 challenge has looked at automatic de-identification [4], identification of smoking status [5], recognition of obesity and co-morbidities [6], and extraction of medication information [7].
Electronic Medical Records and Genomics (eMERGE) Network - a multi-center project focused on the use of data in EHRs to facilitate the study of how genetic variability contributes to health and disease [8]. One of the foci includes the use of NLP for extracting data from clinical narratives and integrating it with other data in the clinical record. One accomplishment of this research to date has been the ability to replicate four of seven known gene-disease associations [9].
SHARP 4 - one of the four collaborative research centers being funded under the HITECH Program to facilitate meaningful use of EHRs, with a focus on secondary use of EHR data.

Another development is the launching this year of a medical records track in the Text Retrieval Conference (TREC) annual information retrieval challenge evaluation. The track will use de-identified records developed by Wendy Chapman and colleagues.

It is also impossible to discuss this topic without acknowledging the discussion around the IBM Watson question-answering system, which recently proved its mettle in a television game show Jeopardy match [10]. IBM has announced some research partnerships that will apply Watson to medical data. This is an interesting research area, but we will need to see real research results to back up the hype [11].

While there are still challenges for clinical NLP, I believe we are seeing a convergence of new methods coupled with growing needs to make use of the increasing volume of clinical data as well as our desire to facilitate re-use of that data for many purposes, such as clinical decision support, quality measurement and improvement, clinical research, and public health reporting and surveillance. While there may be generalizable approaches yet to be discovered, I suspect that evolution will be much like clinical decision support, which has been more successful when engineered to specific domain areas. But as we have also seen with clinical decision support, the ability to perform those specific tasks successfully will be highly valuable to healthcare.

References

1. Stanfill, M., Williams, M., et al. (2010). A systematic literature review of automated clinical coding and classification systems. Journal of the American Medical Informatics Association, 17: 646-651.
2. Hersh, W. (2005). Evaluation of biomedical text mining systems: lessons learned from information retrieval. Briefings in Bioinformatics, 6: 344-356.
3. Hersh, W., Crabtree, M., et al. (2002). Factors associated with success for searching MEDLINE and applying evidence to answer clinical questions. Journal of the American Medical Informatics Association, 9: 283-293.
4. Uzuner, O., Luo, Y., et al. (2007). Evaluating the state-of-the-art in automatic de-identification. Journal of the American Medical Informatics Association, 14: 550-563.
5. Uzuner, O., Goldstein, I., et al. (2008). Identifying patient smoking status from medical discharge records. Journal of the American Medical Informatics Association, 15: 14-24.
6. Uzuner, O. (2009). Recognizing obesity and comorbidities in sparse data. Journal of the American Medical Informatics Association, 16: 561-570.
7. Uzuner, O., Solti, I., et al. (2010). Extracting medication information from clinical text. Journal of the American Medical Informatics Association, 17: 514-518.
8. McCarty, C., Chisholm, R., et al. (2010). The eMERGE Network: a consortium of biorepositories linked to electronic medical records data for conducting genomic studies. BMC Genomics, 4(1): 13. http://www.biomedcentral.com/1755-8794/4/13.
9. Denny, J., Ritchie, M., et al. (2010). PheWAS: Demonstrating the feasibility of a phenome-wide scan to discover gene-disease associations. Bioinformatics, 26: 1205-1210.
10. Ferrucci, D., Brown, E., et al. (2010). Building Watson: an overview of the DeepQA Project. AI Magazine, 31(3): 59-79. http://www.aaai.org/ojs/index.php/aimagazine/article/view/2303.
11. Anonymous (2011). IBM to Collaborate with Nuance to Apply IBM’s "Watson" Analytics Technology to Healthcare. Armonk, NY, IBM. http://www-03.ibm.com/press/us/en/pressrelease/33726.wss.

PCAST Report: What's the Big Deal?

2011-03-03T14:50:00.000-08:00

As anyone who works in informatics knows, there is unremitting stream of reports, white papers, blog entries, and other writings from various government agencies, non-profit organizations, consultants, research organizations, and others involved in health information technology (HIT). Some of these reports promote various points of view, including policy directions, while others present interesting ideas to read. (Some do neither!)

One recent report has garnered more attention than any in the last several months (perhaps since the release of the meaningful use rules). This is of course the recent report from the President's Council of Advisors on Science and Technology (PCAST) entitled, Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward, which was released in December, 2010. This report, called the “PCAST report” by many, has gained high visibility, perhaps reflecting its origin from the White House. It has led the Office of National Coordinator for HIT (ONC) to ask its HIT Policy Committee to create a workgroup tasked with collecting and analyzing public comments and making recommendations relative to current and future ONC activities.

The report states its case by noting that current HIT systems do not meet their potential, mainly due to the lack of interoperability that results from proprietary data stores (mostly in proprietary systems) that blunt the free flow of data. This is hardly new. The report goes on to advocate what it views as the critical solution to the problem, which is the development of a “universal exchange language” (abbreviated by some though not in the report as “UEL”) based on the notion of data elements being reduced to their atomic core. It advocates that each of these core elements have metadata (“data about data”) tagging that includes the element and its value along with an identity of the patient, a patient-controlled privacy designation, and other provenance information about the element.

The report has certainly generated a great deal of discussion, with most of the major organizations involved in HIT having weighed in during the ONC comment period. The report certainly piqued my interest, since I have always held the view that data is the most critical aspect of everything we do with HIT. I agree with Dr. Blumenthal that data is the “lifeblood” of medicine, and my informatics nirvana consists of data freely flowing between systems and the appropriately authorized people to use it. In my dream world, one could be in one EHR and “Save as…” the data for loading into another EHR or some other application. The data would be so interoperable that any application would recognize documents (e.g., discharge summaries or progress notes), measurements (e.g., vital signs or lab values, and structure data (e.g., prescriptions).

So where does PCAST fit into all of this? In this posting, I will review the PCAST Report, summarize the commentary and criticisms, and give my own further analysis to get others thinking (as a good educator should!).

The report begins with the usual accolades for how HIT has the potential to transform healthcare. In addition to the usual improving clinician access to patient data and decision support, involving patients in their care, and enabling public health and clinical research, the report also notes that HIT can create new markets and jobs for technology as well as support healthcare reforms, including economic changes in the system. It lays out nine use cases that benefit patients, clinicians, public health, and clinical research.

However, the report notes, HIT has fallen short of its promise for four reasons. First, most current systems are proprietary applications not easily adapted into clinical workflow, with proprietary data formats not easily exchangeable. Data is not easily disaggregated or re-aggregated. Second, most healthcare organizations focus on the internal value of EHRs and have no incentive for secondary or external uses of their data for patients, other healthcare organizations, public health, or research. A third reason is that patients have concerns about the privacy and security of information of their data. Finally, the report notes that HIT has been largely focused toward administrative functions and not on improving healthcare.

The UEL will require a common infrastructure for locating and assembling data elements of a patient’s records via secure data element access services (DEAS). Data would remain local, and DEAS would be distributed, intercommunicating, and interoperable. A single appropriately authorized query would be able to locate and assemble a patient’s record across multiple DEAS.

The essential core of the report is Chapters 4-5 (pp. 39-52), which deal with the core of the technology and privacy. Chapter 4 asserts that the approach of applications as “services” does not scale up. (Though the authors seem to violate the notion of separating the application and the data.) It is argued that a better approach for healthcare data is the UEL, which is coded in (eXtensible Mark-up Language) XML and tagged with three metadata elements (in addition to the data and its value):

Identifying information about patient – including information enabling location of the data (not necessarily a universal identifier)
Privacy protection information – who may access the data, for what purposes, and either in an identified or de-identified state
Provenance of data – date, time, equipment used to collect data, personnel who collected it, etc.

The UEL would aim for semantic interoperability. While adherence to specific controlled terminology sets would not be required, it would be strongly encouraged. This would allow over time for data to truly be represented in a universal way.

DEAS activities would include “crawling, indexing, security, identity, authentication, authorization, and privacy.” Queries would be issued against all DEAS on the Internet, and results could be re-constituted into a complete picture of patient. Governments, healthcare organizations, and others would operate the DEAS. In some way, this process would act like Web search engines, although they would need to have very high recall and precision to insure all the appropriate data was retrieved, while incorrect data was not. In conclusion, the chapter claims the UEL is extensible, extractable by middleware, and will lead to innovative uses and applications.

Chapter 5 lays out the privacy and security aspects of the UEL and DEAS. In essence, each and every data element would have a patient-controlled privacy attribute, allowing access to the element and its use in identified or de-identified scenarios. All data would be encrypted, which would not only protect security, but also insert a mechanism to audit access.

A number of leading HIT organizations took the opportunity of the ONC comment period to state their positions. While all applauded the raising of awareness of issues related to data and its interoperability, they also raised a number of criticisms. Many advocated that the PCAST Report serve as a broader vision rather than holding concrete solutions.

The comments about the report can be summarized as follows:

The constellation of current standards, as imperfect as they are, meet many of the data-related goals laid out by the report.
Many of the ideas of the report, while interesting and worthy of further research, are untested. Having them be the drivers of Stage 2 of meaningful use would be a substantial change in direction and put the larger HITECH Program at risk.
Clinical data has context, and reducing its entirety to atomic elements has the potential to lose that context. Re-constituting it may not be possible if that context is lost.
Much of the context in clinical data requires that records be more document-centric or at least structured in groups of elements. Disaggregating documents could lose the context they provide.
While everyone agrees that structured data is most desirable, some data in healthcare is too nuanced, and unstructured text is required to describe it.
While industry-wide standards are important, no industry with data as complex as healthcare has tried an approach like this.
The notion of setting privacy at the individual element is highly problematic. Allowing the patient to choose which elements can be seen or not seen by clinicians, researchers, or others could introduce many unintended consequences. It would be preferable for the patient to specify general privacy policies that are then referenced by the data elements.
Patients’ views of privacy may change over time, as diseases change and their own disease course changes.
Search engines are imperfect. The DEAS would need to operate at high levels of recall and precision that are unprecedented for Internet-based search mechanisms.
While the report correctly notes that current HIE efforts are struggling, it ignores that major reasons for this, which have more to do with the lack of a business model for HIE than anything about the technology.

A number of specific comments from these organizations are poignant:

American Hospital Association (AHA) - The report should set a broader vision rather than focus on concrete solutions. Setting privacy at element level could fracture the patient record. Tagging each piece of data could be costly and inefficient. DEAS are likely to face same challenges as HIEs, with lack of a business model. ONC should change policy direction for Stage 2 of meaningful use only with great caution.
Radiological Society of North America (RSNA)/American College of Radiology (ACR) - Echoed many of the same comments and noted we need a uniform method to manage patient identity.
Integrating the Healthcare Enterprise (IHE) USA - Noted that the current IHE profiles cover most of the functionality required for the 9 use cases.
Healthcare Information and Management Systems Society (HIMSS) -Privacy is contextual and changing, especially as diseases change and information about them becomes less sensitive. Encryption of the data elements provides security and an audit trail but can adversely impact workflow. The objectives of the report might not be possible without a universal patient identifier. By atomizing data, we run risk of data becoming dissociated and not being able to detect errors, so any grouping in the source data should be maintained. Metadata tagging should be virtual and not physical. Tags should be referenced and not attached, since some (e.g., privacy) might change over time. Data elements separated from documents and records potentially robs them of their context.
HIMSS Electronic Health Record Association (EHRA) -It is better to tag data on document or record level. The privacy approach is potentially unworkable. A large-scale effort of this approach is untested.
AMIA - Chapter 4 provides general ideas but no details nor references. There is no evidence that this approach will lead to improved care. The report was for the most part silent about other federal agencies, especially the National Library of Medicine, which has great expertise in some aspects of the proposed approach, especially related to terminology development and usage. The report underestimates the complexity of modeling the domain of medicine. It ignores past failed efforts along similar lines, such as the caBIG caDSR project. The DEAS may not be scalable or practical. ONC should not deviate from already tight timeline of Stage 2 of meaningful use. We can learn lessons from the slow adoption of HL7 Version 3, which is not suited to efficient description of task information models. There is too much focus on healthcare and not enough on health.

Other organizations that weighed included:

And of course, a number of bloggers had things to say. As always, John Halamka provided great early summaries of the report and the deliberations of the ONC HIT Policy Committee:
http://geekdoctor.blogspot.com/2010/12/spirit-of-pcast.html
http://geekdoctor.blogspot.com/2011/01/primer-on-xml-rdf-json-and-metadata.html
http://geekdoctor.blogspot.com/2011/01/example-for-pcast.html
http://geekdoctor.blogspot.com/2011/01/general-principles-of-universal.html

In a widely cited posting, Wes Rishel noted some critical points: Information flow for patient care occurs at the level of documents. Taking elements out of larger context can lose context. PCAST data elements are actually molecules, not atoms. There are plenty of molecule definitions, these should be used. Another well-known blogger, Keith Boone, added that a good deal of what the report hopes to accomplish can be done with existing standards.

What will be the impact of the PCAST report? We will find out for sure in April when the ONC releases its analysis and plans for incorporating the report’s ideas and proposals. If nothing else, the report has led to increased discussion about the importance of data interoperability, which even its critics applaud. My hope is that there is at least an acceleration toward the vision of interoperable data that most in informatics share.

Some Supplemental Information from the PCAST Report

The nine use cases were lumped into three categories based upon to whom they provided value.

Value to patients:

Patient on warfarin wanting to know if it is safe to take an NSAID drug for an injury.
Woman with lung mass newly discovered in a community hospital referred to a large academic medical center.

Value to clinicians:

Internist developing primary care medical home.
Small practice with clinicians sharing records and communicating with patients via email.
Cardiology clinics in a part of country collaborating to improve care for patients with recent myocardial infarction.
Family physician embedding alerts in practice to improve preventive care.

Value to research and public health:

Physician caring for a patient enrolled in a national clinical trial.
FDA carrying out post-marketing surveillance of adverse reactions to drugs.
Communities or states measuring improvement toward health goals.

The final published conclusions of the report were:

HHS and ONC have laid a foundation for progress under meaningful use and HITECH.
Achievement of goals for healthcare involves accelerated progress toward robust health information exchange.
Effort should now focus on development of a universal exchange language that enables data to be shared and re-assembled across institutions, subject to strong privacy safeguards based on patient privacy preferences.
Creating these requirements is technically feasible.
ONC should move rapidly to develop these capabilities for stages 2 and 3 of meaningful use.
CMS should modernize and restructure its IT platforms to serve as a driver for progress in health IT.

Follow-up from HIMSS

2011-02-24T12:47:00.000-08:00

This year's Healthcare Information Management and Systems Society (HIMSS) Annual Conference in Orlando, Florida was interesting and enjoyable as always. Clearly the focus was on healthcare organizations and vendors achieving meaningful use of electronic health records (EHRs) . However, there was also plenty of other buzz on topics such as health information exchange, the impact of the departure of Dr. Blumenthal, and changes going on in Washington, DC.

There was also, of course, much talk about health IT workforce issues and the ONC Workforce Development Program. I was video-interviewed on aspects of the topic by:

Joseph Conn of Modern Healthcare, who produced a six and a half minute video on workforce issues and educational programs
Mary Stevens of CMIO Magazine, who produced a three and a half minute video on education and career opportunities for physicians, especially those aspire to be CMIOs.

Accolades for the Informatics Professor and His Blog

2011-02-19T18:40:00.000-08:00

I have had the opportunity to publish and speak in some high-profile venues lately, and my blog and my book have received some honors. For the sake of the reader, however, I will roll all of my "bragging" into just this single post.

Let me start with publishing, where I have been invited to make some commentaries on various aspects of informatics. One of these was a contribution to a series of commentaries on the HITECH program in the prestigious journal Nature. (Subscription required for HTML and PDF versions.)

Another was an invitation to write an editorial accompanying a study on the development of registries in chronic kidney disease in the journal, Clinical Journal of the American Society for Nephrology (subscription required).

I have also be invited to talk on panels at a couple of high-profile meetings. One talk was on a panel at the AcademyHealth National Health Policy Conference (February 7-8, Washington, DC). The panel was focused on workforce issues, with speakers addressing different aspects of the healthcare workforce issue. Naturally I was invited to speak on informatics issues, describing the ONC Health IT Workforce Program as well as informatics competencies for modern healthcare professionals (slides).

Another talk is on a panel at this week's HIMSS Annual Conference on the ONC Health IT Workforce Program. I will speak about the Health IT Curriculum Development Centers Program (slides). OHSU serves not only as one of the five Curriculum Development Centers but also the National Training & Dissemination Center tasked with disseminating the curricular materials via a Web site and training community college faculty in their use.

I am also pleased to report that the Informatics Professor blog has been recognized by three sites that rate blogs:

Finally, I am honored to have my book reviewed by one of my favorite blogs, Keith Boone's Healthcare Standards blog. It turns out that Keith did some work in search earlier in his career and has some poignant things to say about my book (and my blog). I look forward to his book on Clinical Document Architecture due out this spring.

Welcome to Oregon, President Obama and Mr. Otellini

2011-02-18T06:10:00.000-08:00

Today I will have the opportunity to attend President Obama's visit to Intel Corp. in Portland, Oregon. While I will just be among the crowd, I would love the opportunity to talk with both of them, and will post my comments of what I would say in this blog entry.

President Obama, I want to thank you for the opportunity afforded by the HITECH Act in your stimulus legislation. I wish we could have you over to visit Oregon Health & Science University (OHSU), where we have put the $5.8 million awarded to us under the HITECH Act to good use. It is an investment in human capital that is building the workforce of future professionals who will lead the "meaningful use" of electronic health records (EHRs) to improve the quality and safety of healthcare. On time and on budget, we are not only one of nine universities training these professionals from around the country, but also one of five universities developing curricular materials for shorter-term community college programs. In the latter program, we also serve as the National Training & Development Center, training and supporting community college faculty in use of the materials and disseminating them via a secure Web site. We have also enhanced the scope of the program by building a curriculum around the VistA EHR system from the Veteran's Administration. This system is another exemplary federal project that has drastically improved healthcare delivery by the VA, and now will provide additional value in training future health information technology professionals in using and configuring EHRs.

To Intel Corp., namely Mr. Paul Otellini, CEO, I would love the opportunity to show off the work being done by a local university, OHSU, in your company's own backyard here in Oregon. I would relish the opportunity to work with your company more to increase economic development and create high-skill, high-paying jobs in Oregon. I have written in this blog, a local tech blog, and even our local newspaper, the Oregonian, about the potential that exists in Oregon for synergy among companies, an innovative healthcare system, and a world class academic program in biomedical informatics at OHSU to create an economic cluster around health information technology. Investing in students, research, and companies could pay off well for our region.

Postscript: I had an enjoyable time visiting Intel and hearing President Obama speak. I managed to get a front row seat and was able to shake the President's hand afterwards. Of course I took pictures and posted some of them on Facebook. I still would love the opportunity to address either the President or Mr. Otellini about the issues raised above.

HITECH: Improving Healthcare Through Data and Action

2011-02-05T06:29:00.000-08:00

Every now and then, I am asked to give an overview of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the “economic stimulus bill”). The centerpiece of HITECH is a plan to vastly expand the adoption and “meaningful use” of electronic health records (EHRs) [1], based on a growing body of research demonstrating that EHRs, especially when combined with clinical decision support (CDS), can improve the quality, safety, and coordination of healthcare [2, 3]. Similar to other areas related to technology and/or healthcare, the US has become a laggard in the adoption of EHRs, falling behind most other developed countries [4].

HITECH provides up to $27 billion for eligible professionals and hospitals to receive incentives for achieving the meaningful use of EHRs [5]. Meaningful use is a critical concept. The goal of HITECH is not just to put computers into physician offices and on hospital wards, but rather to use them toward five goals for the US healthcare system: improve quality, safety and efficiency; engage patients in their care; increase coordination of care; improve the health status of the population; and ensure privacy and security. As such, every criterion in meaningful use (e.g., drug-drug interaction checking) must tie back to a healthcare goal (e.g., improve quality, safety and efficiency).

Government funds for HITECH incentives will be distributed through the public Medicare and Medicaid reimbursement systems. Depending on choice of funding through Medicare or Medicaid, eligible professionals can receive $44,000-$63,000, while eligible hospitals can receive $2-9 million between 2011 and 2018. The main purpose of these incentive funds is to cover the costs of investment in EHR systems. It is anticipated that further costs will become part of the "costs of doing business" for healthcare.

The HITECH legislation recognizes that incentives alone will not be enough to achieve all the goals of meaningful use. As such, HITECH allocates an additional $2 billion for various human and organizational infrastructure elements to attain its mandates. A critical portion of this infrastructure is the ability to achieve health information exchange (HIE), which is the secure flow of data to wherever it is needed for patient care, including across traditional business and other boundaries in the healthcare system [6]. About $547 million is allocated to states for HIE development.

Another critical piece of the infrastructure is the provision of technical support to achieve meaningful use. This is done with the allocation of about $677 million to 62 regional extension centers that are providing a variety of forms of assistance, mainly to small primary care practices [7].

An additional portion of the required infrastructure is a competent professional workforce to develop, implement, and train users of EHR and related systems. It has been estimated that the HITECH agenda will require an additional 50,000 professionals trained in fields such as biomedical informatics and health information management [8]. About $118 million has been allocated for both short-term training programs in community colleges as well as longer programs mostly at the graduate level in universities. My institution, Oregon Health & Science Univeristy, is playing a major role in this program.

The HITECH legislation also recognizes that additional research and development is required. As such, $60 million has been allocated to establish four collaborative research centers focusing on the topics of security and health information technology, patient-centered cognitive support, health care application and network design, and secondary use of EHR information. A related funding initiative is the Beacon Communities Program, which has funded about $250 million for 17 advanced demonstration projects “shine the light” forward.

Just as meaningful use connotes that EHR adoption is not just about installing computer technology in clinical settings, there are related initiatives in the United States that will synergize with the substantial HITECH investment. One initiative from the Institute of Medicine aims to develop the “learning health care system” that learns from the growing volume of captured data what does and does not work in healthcare [9]. This is closely related to the growing push for “comparative effectiveness research” that aims to compare tests, treatments, and other medical activities in head-to-head studies carried out in real-world settings [10]. This infrastructure will also likely contribute to the growing push for translational research, as exemplified by funding for the Clinical & Translational Science Award (CTSA) program of the National Institutes of Health [11].

Taken collectively, all these programs from HITECH to ACA, the learning healthcare system, and CTSA provide a vision of a new healthcare system that learns from its successes and changes based on its mistakes. This vision uses data as the critical enabler of coordinating, measuring, and researching care. HITECH is indeed a grand experiment, and it is likely be that some elements of this experiment will succeed whereas others fail. But in the end, the healthcare system should benefit this unprecedented investment in information systems, human capital, and goals for improving health.

References

1. Blumenthal D, Launching HITECH. New England Journal of Medicine, 2010. 362: 382-385.
2. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Journal of the American Medical Association, 2005. 293: 1223-1238.
3. Goldzweig CL, Towfigh A, Maglione M, and Shekelle PG, Costs and benefits of health information technology: new trends from the literature. Health Affairs, 2009. 28: w282-w293.
4. Schoen C, Osborn R, Doty MM, Squires D, Peugh J, and Applebaum S, A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Affairs, 2009. 28: w1171-1183.
5. Blumenthal D and Tavenner M, The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 2010. 363: 501-504.
6. Vest JR and Gamm LD, Health information exchange: persistent challenges and new strategies. Journal of the American Medical Informatics Association, 2010. 17: 288-294.
7. Maxson E, Jain S, Kendall M, Mostashari F, and Blumenthal D, The regional extension center program: helping physicians meaningfully use health information technology. Annals of Internal Medicine, 2010. 153: 666-670.
8. Hersh W, The health information technology workforce: estimations of demands and a framework for requirements. Applied Clinical Informatics, 2010. 1: 197-212.
9. Eden J, Wheatley B, McNeil B, and Sox H, eds. Knowing What Works in Health Care: A Roadmap for the Nation. 2008, National Academies Press: Washington, DC.
10. Murray RK and McElwee NE, Comparative effectiveness research: critically intertwined with health care reform and the future of biomedical innovation. Archives of Internal Medicine, 2010. 170: 596-599.
11. Zerhouni EA, Translational research: moving discovery to practice. Clinical Pharmacology and Therapeutics, 2007. 81: 126-128.

Electronic Health Records Do Not Impact the Quality of Healthcare?

2011-01-26T12:56:00.000-08:00

The headlines have blared the news this week that a new study published in Archives of Internal Medicine showed that electronic health records (EHRs) in the ambulatory setting do not appear to lead to higher quality patient care [1]. This in turn has led many leading news organizations to have stories with headlines such as, Stanford researchers find EHRs don't boost care quality.

For those of us who work in informatics, this is a pretty serious finding. As responsible scientists and citizens, we cannot ignore negative results about the work we do. However, we also have an obligation to place this work in the larger context of all research on the relationship between health information technology (HIT) and quality of medical care.

Like almost all science that gets reported in the general media, there is more to this study than what is described in the headlines and news reports. The study was published in a prestigious medical journal by two Stanford researchers. The implementation of the research methods they used appears to be sound. There is no reason to believe that the results obtained do not derive from the methods used.

However, there are serious limitations to this type of study and to the data resources used to answer the researchers' question, which was whether ambulatory EHRs that include clinical decision support (CDS) lead to improved quality of medical care delivered. While I do believe this study has a place in the evidence base of HIT, it suffers from limitations that are inherent in studies like this that that are observational, correlational, and retrospective. This study used a data source collected for other purposes, the National Ambulatory Medical Care Survey, and compared physicians who were identified users of CDS with those who were not to see if there were differences in the quality of care they provided based on 20 process quality measures. The results found there were no differences between the groups, i.e., those using EHRs and CDS did not deliver higher quality care than those not using them.

Before delving into the details, it is also worth noting that this study is not the first to apply this methodology. Within the last couple months, two other studies have used a similar approach to assess associations between quality measures and hospital EHR adoption [2] and computerized provider order entry [3], giving mixed results, i.e., some measures showing benefit and others not. In addition, Archives of Internal Medicine published another study using this sort of approach in 2009 showing that hospital notes, test results, order entry, and decision support were variably associated with improved patient outcomes and reduced costs [4]. (It was surprising to see the latter not referenced in the article.) If we were to take all of these studies as definitive, then we might conclude that EHRs usage in hospitals improves quality of care, even if EHR usage does not in ambulatory settings.

But whether the results are favorable or not, it is important to understand some serious limitations in these types of studies and this one in particular. A first limitation is that the study looks at correlation, which does not mean causality. This was an observational and not an experimental study. The data used for the study was not collected for the purposes of assessing the quality of care by EHRs. As with any correlational study, there may be confounders that cause the correlation or lack of it. As we know from evidence-based medicine, the best study design to assess causality is an experimental randomized controlled trial. Indeed, such studies have been done and many have found that EHRs do lead to improvements in quality of care. There have been several systematic reviews of such studies noting that while some of the studies suffer from methodologic limitations, others are well-designed and do demonstrate positive value for various aspects of EHR and CDS [5-7]. There is a continuing stream of such studies and two have been published in the last couple months. One showed that an EHR with targeted CDS led to increased improvements in glucose control in diabetics [8], while another found that a real-time alert cut inappropriate use of D-dimer testing by 70% [9]. Not all such studies demonstrate positive results, but enough to do to show that there is value in the well-informed use of HIT.

A second limitation of this study is the quality measures used. Quality measures are of two general types, process and outcome. Process measures look at what was done, such as ordering a certain test or prescribing a specific treatment. Outcome measures look at the actual clinical outcomes of the patient, e.g., whether there was a reduction of mortality, complications, or cost. It is a fair criticism of the current state of the healthcare quality movement that most measures used (including those in the meaningful use criteria) are process measures that may or may not result in improved patient outcomes.

A third limitation of this study is that we do not know whether the physicians using EHRs and CDS had decision support in place to impact the specific quality measures that the researchers studied. While the quality measures are important process measures for physicians to adhere to, they may not be amenable to CDS generally or the CDS used in these systems.

A fourth limitation is that the study assesses episodes of care and not longitudinal care over time. This may not portray an accurate picture of a physician's practice.

A fifth limitation is that the data analyzed was collected in 2005-2007. While EHRs and CDS were available at that time, they were less widely used and less mature at that time.

Finally, we have no idea how well trained these physicians were at using the CDS that they had. We know that success with HIT is based on many factors that go well beyond the technology itself, such as proper implementation and training. Well-designed research must address these factors too.

There are also some other limitations to the study that are discussed in an accompanying editorial that unfortunately few people, especially those who get news of the study from news reports as opposed to the journal itself, will read. The editorial writers appropriately point out that other studies, including experimental ones, have shown value for HIT interventions.

The results of this study are a legitimate addition to the evidence base of informatics and cannot be dismissed out of hand. However, these findings must take their place in the proper context of all research on HIT. If nothing else, this study highlights the need for more and better research to truly identify where HIT helps, has no impact, or outright harms patients.

References
1. Romano MJ and Stafford RS, Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives of Internal Medicine, 2011: Epub ahead of print.
2. Jones SS, Adams JL, Schneider EC, Ringel JS, and McGlynn EA, Electronic health record adoption and quality improvement in US hospitals. American Journal of Managed Care, 2010. 16: SP64-SP72.
3. Kazley AS and Diana ML, Hospital computerized provider order entry adoption and quality: an examination of the United States. Health Care Management Review, 2011. 36: 86-94.
4. Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, and Powe NR, Clinical information technologies and inpatient outcomes: a multiple hospital study. Archives of Internal Medicine, 2009. 169: 108-114.
5. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Journal of the American Medical Association, 2005. 293: 1223-1238.
6. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al., Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 2006. 144: 742-752.
7. Goldzweig CL, Towfigh A, Maglione M, and Shekelle PG, Costs and benefits of health information technology: new trends from the literature. Health Affairs, 2009. 28: w282-w293.
8. O'Connor PJ, Sperl-Hillen JM, Rush WA, Johnson PE, Amundson GH, Asche SE, et al., Impact of electronic health record clinical decision support on diabetes care: a randomized trial. Annals of Family Medicine, 2011. 9: 12-21.
9. Palen TE, Price DW, Snyder AJ, and Shetterly SM, Computerized alert reduced D-dimer testing in the elderly. American Journal of Managed Care, 2010. 16: e267-e275.

Reflections at the End of Another Amazing Year for Informatics

2010-12-31T07:01:00.000-08:00

Last year, in wrapping up the first year of the Informatics Professor blog, I marveled at how amazing the year of 2009 had been. I noted that the year started with both uncertainty and hope; the former fueled by the recession and the precarious financial state of Oregon Health & Science University (OHSU) due to that recession and the latter driven by the excitement of the election of President Barack Obama and (at least for me) the hope for real change. By the end of 2009, it was clear that profound change had indeed occurred, if not generally then at least in the biomedical and health informatics field.

The hope and change, of course, were driven by the HITECH program with the president's economic stimulus package. At the end of 2009, the path forward was clear: health information technology would be driven by the concept of "meaningful use," and the part nearest and dearest to my heart, education and training, would be driven by the ONC Workforce Development Program, which itself was driven by Section 3016 of the HITECH Act that I played a role in influencing.

I spent the latter days of 2009 and early part of 2010 writing proposals, in particular for the curriculum development program and the university-based training program. With the Funding Opportunity Announcements (FOAs) for these and other programs, such as Beacon, SHARP, and regional extension centers, released in December and due in January, many in the informatics field lamented that ONC stood for the "Office of No Christmas." I spent a good part of my winter break last year working on these proposals. The only enjoyable aspect of the process was that they allowed us to envision how we could implement the educational programs we always dreamed of if we ever had the money, which now it looked like we did.

The most harrowing part of the year was the time between the submission of the proposals and receiving word about funding. As well-positioned as we were to receive these competitively awarded proposals, there was an undercurrent of fear that perhaps we forgot to address some required aspect of the program or that some reviewer felt we had taken the wrong approach. In all honesty, it would have been quite an embarrassment to not be selected for funding, since OHSU's program laid the groundwork for some of the thinking that had emerged surrounding health IT workforce development.

All the agony came to an end on Friday, April 2nd, when I awoke in the morning to find out that both OHSU proposals had been funded. For the curriculum development project, we were not only funded as one of the five curriculum development centers, but also chosen as the lead National Training and Dissemination Center (NTDC). For the university-based training program, we were one of nine programs selected for funding tuition assistance in our graduate program. A common quip in academia is that the downside to getting grants funded is that you then have to do the work. However, this was literally a dream come true. Between both grants, we were funded for $5.8 million to do what we always envisioned we could do if we had the funding. While the short-term emphasis of the funding (due to their being stimulus funds) required us to make some decisions we might otherwise not make, it was still a great position in which to be.

Also on the second to last day of 2009, the preliminary meaningful use rules were released. These were followed by a 60-day comment period, modification of the rules, and the release of the final rules on July 13th. I happened to be in a hotel room in Singapore (10 pm local time, 10 am Eastern time) when listening to their unveiling. While everyone had qualms with this criteria or that criteria, I believe that the majority of people were content with the approach to meaningful use taken by ONC.

With our own projects, we hit the ground running. Out of the gate, the curriculum development project required the most work up front. After a two and a half day workshop in Washington, DC the second week of the grant, we began our long quest that would result in the first version of the curriculum being developed and handed off to the community colleges by the end of October. Being the NTDC, OHSU also had to organize a training event for community college faculty in August and launch a Web site for dissemination of the materials around that time, both of which we did. We even added an aspect to the project of creating an educational version of the VA VistA electronic health record system.

The university-based training grant project was a little slower to get started, but not by much. With funding for 135 Graduate Certificate and 13 master's degree students over three years, our plan was to use the funding mainly as a form of tuition assistance for new students entering the field. We started providing support for students in the summer academic quarter and really ramped up in the fall. The main regret is that we have received two to three times as many qualified applicants as we having funding to accept. A decent proportion of those individuals have enrolled as self-funded students.

While a good proportion of my year was spent around these ONC initiatives, there were other achievements as well. Due to ONC and other funding, the Department of Medical Informatics & Clinical Epidemiology catapulted to second among the 25 departments at OHSU in external funding. We have many other initiatives in comparative effectiveness research, bioinformatics, and related areas. The big challenge for the department in 2011 and beyond is how to consolidate and build upon the success of the stimulus-era funding. I am confident we will find ways to do this, as the need for our disciplines to advance healthcare, personal health, and biomedical research will not diminish even as the federal budget tightens.

The coming year will also be an interesting one for the informatics world. How many eligible professionals and eligible hospitals will achieve meaningful use? What unforeseen bumps in the road will emerge? How will healthcare reform impact the use of health information technology? What will happen to healthcare reform itself? One thing is certain: we will live through exciting times!

I have now been writing this blog for almost two years. I have been pleased to have this type of forum to share my views on various aspects of my work. I am also pleased that others have noticed, not only the 129 people who follow the blog, but also winning awards like being on the list for the 2010 Top Math & Science Professor Blogs Award.

I plan to keep running the blog pretty much like I have been, with a fewer number of more substantive posts than the stream of consciousness approach used by many other blogs. I do hope to branch out a little bit more this coming year beyond workforce and education, as I occasionally did this year.

The Comfort of Connectivity

2010-12-17T04:48:00.000-08:00

My family, friends, and colleagues believe I spend way too much time keeping up with my email and related work activities, even when I am on vacation, as I am now. They are probably right, as I type this while on vacation in lovely Oaxaca, Mexico.

Maybe it is because I remember the days when email and Internet connectivity from afar were hit or miss. Now, however, I have to admit that I marvel at the ease of accessing Wi-Fi and even my Verizon smartphone (phone, texting, and Internet on my Droid) from this lovely city that is not exactly at the forefront of technology. I am staying in a mid-range apartment, which has Wi-Fi, as does the Instituto Cultural de Oaxaca, where I am studying Spanish for a couple weeks. (The Droid is a wonderful helper for learning Spanish, as I am using two apps for Spanish-English dictionaries.) Since everything on my Droid works here, I am even able to set up a 3G mobile hot spot in a pinch!

Many eating, coffee, and other establishments have Wi-Fi as well, even the Parque El Llano a couple blocks from our apartment. My Droid has even worked in most of the small villages outside of Oaxaca. Perhaps even more amazing was that some homes in these poor villages actually have broadband Internet.

I truly am trying to take a vacation and only responding to critical emails. I have to admit there is a certain comfort to know that my connectivity is there, even if I am trying to minimize its use. I am reading my emails if for no other reason to not have thousands awaiting my return from this two and a half week vacation.

Of course, my physical and virtual lives are so merged that it would be very difficult to not use my computer and access the Internet, even when on vacation. I certainly enjoy taking pictures with my digital camera and sharing them. I also do a good deal of my news reading these days on-line. And of course there are my many friends and others on Facebook with whom I enjoy interacting. In addition, figuring out the details of visiting tourist sites, restaurants, and other places is greatly facilitated when one has Internet access. So it would be truly difficult if not impossible to completely unplug.

There is literally no place on the planet where the Internet is not accessible these days. In the past few years, I have connected from places such as Zimbabwe and Cuba. While ubiquitous global connectivity has some drawbacks, I firmly believe it is positive overall, and the ease of communication and sharing can foster better relations among peoples of the world.

10x10 ("Ten by Ten") at the End of 2010 and Beyond

2010-12-08T05:12:00.000-08:00

With the end of 2010 approaching, I am asked with increasing frequency whether we met the goals set out by the 10x10 ("ten by ten") program, which was launched in 2005 with the goal of training 10,000 healthcare professionals in informatics by the year 2010. Now that 2010 is coming to an end, how did we do?

I can say that the program has been an unqualified success. The OHSU 10x10 offerings trained nearly 1000 (999, to be precise) people, with another eight universities training an additional 258 more, for a total of 1257 from 2005-2010. Many of those of completing the program have enhanced their current careers. From the OHSU courses, about 15% pursued additional training in the field. While our numbers did not add up to 10,000, there was clearly value for those who completed the course. The program also helped expand educational capacity in the field generally and highlighted the need that led to legislation such as Section 3016 of the American Recovery and Reinvestment Act (ARRA) and the resulting ONC Workforce Development Program.

The 10x10 courses are offered on-line, with an in-person session at the end that brings participants together face to face. The amount of material in each course is roughly comparable to an introductory three-credit graduate-level course, as shown in the syllabus from the OHSU course. In a demonstration that the Internet knows no boundaries, the course has attracted participants from all corners of the globe, such as Argentina, Hong Kong, Singapore, Israel, Pakistan, South Korea, Saudi Arabia, China, India, and Nigeria. The enthusiasm from Latin America led a group from Hospital Italiano of Buenos Aires to translate the course into Spanish and offer it across Latin America. About 500 individuals have completed this version of the course from a number of Spanish-speaking countries. Another version of the OHSU course has been offered in Singapore four times, with the in-person session held in Singapore.

We absolutely plan to continue the 10x10 program beyond the end of 2010. Two more OHSU offerings started in late 2010, along with a few more from other universities. There are no plans whatsoever to end the program, whose need continues to be demonstrated as increasing numbers of healthcare professionals and hospitals seek to achieve "meaningful use" of electronic health records. Of course, biomedical informatics is about more than meaningful use and EHRs, as demonstrated in the course syllabus.

AMIA has already changed the tag line of the program from "10,000 Trained by 2010" to "Training Next-Generation Informatics Leaders." Maybe we should just say that 10x10 now the program that aims to train 10,000 individuals in biomedical and health informatics without giving a specific deadline. Clearly the need remains.

The end of 2010 is also a time to reflect on how we arrived here. In 2005, Dr. Charles Safran, who was then President of the American Medical Informatics Association (AMIA), began taking an interest in the informatics capacity of healthcare organizations. In a letter to the editor of JAMA, he stated that each hospital in the US should have at least one physician and one nurse trained in informatics. Meanwhile, AMIA was looking to beef up its e-learning offering, but found new development of content would be prohibitively expensive. At the same time, I had already been offering the introductory course in the OHSU Biomedical Informatics Graduate Program on-line for some time. It was apparent that we could repackage the course relatively easily. Building on Charlie's call, I coined the name 10x10, aiming to train 10,000 people within five years, by 2010.

I have thoroughly enjoyed developing and teaching the 10x10 course. It has been personally gratifying to meet so many people who took the course and found it of value. I am delighted that some colleagues from Argentina translated the course to Spanish, as noted above. The course name even made its way into legislation in a bill that passed the US House of Representatives (though not the US Senate), the 10,000 Trained by 2010 Act introduced by Congressman David Wu (D-OR). A demo version is available for those who want to take a look.

Some have asked why the Chair of a department would enjoy teaching the introductory course so much. I take great satisfaction in providing people their first introduction to the field of biomedical and health informatics. I enjoy the give and take with students, including those who challenge me. The 10x10 course and my other educational accomplishments make it clear that these activities are my passion and calling in life.

The Emergence of the Informatics Practitioner

2010-11-20T05:33:00.000-08:00

There have been many changes in the biomedical and health informatics field since its inception in the 1960s and even since my entry into it in the late 1980s. Some of these changes have been due to changes in technology, e.g., from the teletype and punch card computers of the 1960s to the advent of personal computers in the 1980s to the current era of high-powered computers and smaller devices connected to the ubiquitous global Internet. Other changes have come from scientific maturation of the field, such as a better understanding of the proper role for computerized clinical decision support and the emergence of enabling technologies from genomics and related areas.

Another area where profound change has occurred is in the professional work of informatics. When the field started to develop in the 1960s, and even when I assumed my first faculty position in the early 1990s, most who worked in informatics thought of themselves as researchers. The primary work of academic informatics departments was research and development. Most who were trained in the field obtained fellowships and/or advanced degrees. While many academic informaticians took on some operational roles in their institutions, the focus of that work was mainly implementing novel cutting-edge technology. Research, meanwhile, focused on developing new systems, models, and algorithms to meet what we thought were the needs of clinicians, scientists, consumers, and others.

Over the last decade, many changes have occurred. One of the biggest of these changes is the emergence of the informatics practitioner (or professional). Now that the use of information technology (IT) has become a routine (if mission-critical) activity of healthcare and other health-related organizations, there is growing recognition of the need for skilled individuals who understand both the technology and its use in a given underlying health domain. These professionals need not be highly technical, though they must be facile with IT and, perhaps more importantly, savvy with the management and analysis of information.

The jobs of informatics practitioners are diverse. These individuals may undertake tasks such as extracting data from "dirty" data sources (such as clinical records) for quality measurement and improvement. They may serve as champions or implementers for information systems to meet the needs of these organizations. They might maintain large bioinformatics databases or use them to analyze the data of researchers with whom they collaborate. At the top end of organizations, the chief information officer (CIO) or chief medical information officer (CMIO) increasingly provide key strategic leadership around information systems and use of the data within them.

A number of academic informatics faculty who grew up in the earlier era have not recognized the change. I have to admit that I realized it earlier than most mainly because of the demands from students in our nascent educational programs asking to learn more about how to implement systems than do research. Many academic leaders still have difficulty discerning between the differences in training researchers and practitioners.

I do not, however, see the emergence of informatics practitioners or educational programs designed for them as being at odds with the research mission of academic informatics departments. In fact, I view it as complementary. All mature fields, certainly those in the health professions such as a Department of Medicine, have both practitioners as well as researchers and educators. The researchers discover new knowledge and techniques while the educators disseminate it to the practitioners. All professions have academic departments whose missions entail both research and education. I see this starting to occur in informatics programs around the world and is certainly the modus operandi of our department at Oregon Health & Science University (OHSU).

With the large IT investments being made in healthcare, public health, and research organizations, along with the need and desire for baby boomers to manage their increasing use of healthcare, I see a bright future for informatics practitioners. The informatician will rightfully take his or her place on the larger healthcare team, delivering needed expertise on the integration and coordination of information for optimizing people's health.

Update on the ONC Workforce Development Program

2010-11-15T03:57:00.000-08:00

It's hard to believe that it has only been a little more than seven months since the Office of the National Coordinator for Health IT (ONC) announced the awardees for its Workforce Development Program. A tremendous amount has been accomplished since the grants were awarded on April 2, 2010. Our department at Oregon Health & Science University (OHSU) has played a substantial role in several aspects of the program.

The ONC Workforce Development Program is devoted to building the professional workforce that will help eligible hospitals and professionals achieve meaningful use of the electronic health records (EHR). The program is based on the need for an estimated 51,000 such professionals who will work in twelve workforce roles. Half of these workforce roles are deemed to be trained in six-month certificate programs in community colleges, while the other half are to be trained in 1-2 years in university-based programs.

The overall program consists of four specific initiatives:
1. Community College Consortia - 84 community colleges, grouped into five regional consortia, have been funded to offer six-month certificate programs in the six community workforce roles.
2. Curriculum Development Centers - Because the community colleges do not have curricula for these programs, five universities have received awards to develop curricular components that are to be developed into courses by the community colleges. One of the five universities (OHSU) was additionally designated the National Training and Dissemination Center (NTDC), tasked with developing the Web site for dissemination of the materials and carrying out training activities for community colleges, including a training event that took place in August, 2010.
3. Competency Examination - An examination to test the competencies gained by graduates of the community college programs for the six workforce roles trained in their programs is being developed.
4. University-based Training (UBT) programs - Additional training funds were awarded to nine universities (including OHSU) for longer-term university-based training.

As noted above, OHSU has been playing a major role in the ONC Workforce Development Program. We are one of the five Curriculum Development Centers and also serve as the NTDC. In addition, we are also one of the nine universities funded under the UBT program.

The work in all of these programs has been substantial over the past seven-plus months. Led by the NTDC, the Curriculum Development Centers have delivered the first version of the 20 curricular components, which are available to the community college programs on the NTDC Web site. The NTDC also put on the training event over August 9-11, 2010 in Portland, OR that brought together over 200 community college faculty, the five Curriculum Development Centers, and some of the ONC leadership.

The Curriculum Development Centers project has spawned another exciting project that will, in the long run, benefit the entire informatics field. This is the development of an educational version of the VA VistA EHR system along with teaching exercises in using and configuring EHRs. The lack of EHR access has always been a problem in informatics education, as vendors have been reluctant to make their systems more readily available. (This is in contrast to companies like IBM and Apple that make development tools available to computer science students for free or at substantial discounts, which makes sense, as it trains a new generation of students in their wares.) This project will rectify this problem and hopefully get vendors to consider ways to be more open with their systems for educational purposes.

OHSU is likewise very busy with its UBT training grant, which will fund 135 Graduate Certificate and 13 Master of Biomedical Informatics over three years. The certificate students are admitted on a rolling basis each quarter (OHSU is on an academic quarter system) and must make the commitment to complete the program in one year. While not requiring full-time study, this pace does require more concentrated commitment than typical part-time students. The program is on-line with no on-campus requirement. We have enrolled 47 certificate students to date and plan to continue admitting 20-30 students per quarter until the funding is completely committed (probably in early 2012). Unfortunately, the number of qualified applicants has vastly exceeded the resources of the grant (about 100 applicants per quarter), although most are offered admission on a self-funded (i.e., paying tuition) basis.

The master's students are admitted in two cohorts, one that started in the fall of 2010 and another that will begin in the fall of 2011. This program is full-time and on-campus.

One novel feature of both programs is the requirement of a practicum (certificate) or internship (master's). We believe that hands-on, real-world experience is essential for learning informatics, even those in on-line programs. We had experience in remote students doing practicums and internships prior to the grant and feel ready to scale up to all of the students funded by the UBT grant. To this end, we have hired a Practicum/Internship Coordinator who will handle the organization and logistics of the program.

We also plan to use the resources of the grant to hire a Career Counselor. This addresses another challenge that informatics programs have faced, which is having the resources to provide career guidance. We have found that generic career advising centers can be helpful to a point, but there is much advice specific to informatics, especially for the students of diverse backgrounds and interests who enroll in our program.

We also hope that in the long run, these enhancements will carry over into our regular program, especially once the ONC UBT grant ends in 2013. I am optimistic that informatics education will continue to be pursued by a variety of students to carry on the work that will not end once the HITECH program finishes. Informatics is and will continue to be a great career option for those wanting to work at the intersection of health disciplines and information technology. As I always say, informatics is more than EHRs, and there will also be continued opportunities in other areas in bioinformatics, other aspects of clinical informatics, public health informatics, and more.

Selected to the Informatics All-Star Team!

2010-11-09T06:03:00.000-08:00

This past week I was awarded with a gratifying honor. I was named by Modern Healthcare magazine as one of the Top 25 Clinical Informaticists in the US. I am truly honored to be among this group, which I view as a kind of all-star team for clinical informatics. I am also grateful to OHSU student Paul DeMuro who nominated me for the honor.

Unfortunately, the article describing the awardees in detail is password-protected. However, the list of the 25 awardees and a brief statement about them, including me, is freely accessible.

A big part of this honor has to do with the fact that I am, as the magazine notes, the only full-time educator among the 25. (There are a few other academics, such as Blackford Middleton and Chris Longhurst.) I am delighted that the award committee chose to recognize the value of informatics education as an important part of clinical informatics.

This is actually not my only recent appearance on a "top" list. A blog called HealthTechTopia named me among the Top 10 Most Influential Informatics Professors.

Health IT Destination: Portland and Oregon

2010-10-27T17:22:00.000-07:00

For several years, I have advocated that the city of Portland and state of Oregon have the necessary ingredients to develop an industry cluster in health and biomedical information technology (IT). I expounded this vision in an Op-Ed piece in the Oregonian in 2008 and in the Silicon Forest blog in 2009.

Some recent happenings in the area make this vision more compelling. First comes news that is not directly related to biomedical informatics but is relevant to the currently beleaguered Oregon economy. This is the plan announced by Intel, one of our major local high-tech employers, to invest several billion dollars in renovating existing production centers and building a new research and development center. This is good news for the local economy due to the promise of high-skill, high-paying jobs. This is synergistic with other local development efforts, including those led by the Portland Development Commission to advance software as one of the four areas it identifies as a key cluster for economic development.

There are also specific instances of highly visible health IT companies, such as Kyrptiq, which just received some investment from the large national e-prescribing company, Surescripts. Oregon also has the cache of a strong open-source software community and the surrounding business activity to make it sustainable, not only generally but also specifically in health and healthcare. A local company that exemplifies this approach is the Collaborative Software Initiative, with its focus on public health.

I have always argued that Oregon is a potential hub for health and biomedical IT because of the confluence of strong industry, innovation in the healthcare delivery sector (Oregon is one of those "high quality, low cost" states), and the presence of a world-class academic program in biomedical and health informatics. I believe that these attributes can combine synergistically to foster economic development, improve the quality of people's health, and provide leadership and innovation in health and biomedical IT.

One encouraging recent happening is the publication of a draft report for comments calling for Portland State University (PSU) and Oregon Health & Science University (OHSU) to expand their collaboration by developing a formal strategic alliance. The report explicitly calls out the potential for developing joint programs in biomedical and health informatics.

There are other cities and regions that aspire to leadership in this area. The city of Atlanta recently published a gloss on its being an "epicenter" of health IT. The larger healthcare entrepreneurship scene in Nashville also includes a component of health IT. I hope the leaders in Portland and Oregon will share this vision.

The Informatics Outlook for Physicians

2010-10-14T10:44:00.000-07:00

In looking over the topics I have addressed in the year and a half of this blog, I have tried to convey biomedical and health informatics as a broad field with many roles and opportunities for people from a wide variety of professional backgrounds. One group that I have not addressed explicitly is physicians.

I admittedly have a kinship for physicians in the informatics field. After all, I am a physician by training, and even though I know longer actively care for patients, my training and early career experience provide a perspective that informs my understanding of the role of physicians in informatics.

Overall, the opportunities for physicians in informatics are substantial and growing. While many early informatics roles for physicians focused on research and development, the real growth opportunities are now for those seeking to be informatics practitioners. These practitioners play a variety of roles not only in planning and implementing systems, but deriving value from the information within them.

An ever increasing number of healthcare organizations have recognized the importance of physician informatics leadership, manifested most frequently in positions that go by the name of Chief Medical Information Officer or Chief Medical Informatics Officer (both of which conveniently are represented by the acronym CMIO). While the CMIO position is probably now the most visible physician role in informatics, it is hardly the only one. Physicians also play other roles in healthcare organizations as well as other entities, such as vendor, consulting, government, and research organizations.

The OHSU biomedical informatics graduate program has always had a strong representation from physicians, who comprise about 50% of our enrollment. They are therefore not the only demographic of student in the program, as we also have students from other healthcare professionals (e.g., nurses, pharmacists, lab/radiology technicians, health information managers) as well as from outside the health professions (e.g., information technology, computer science, and even further afield from law, biology, business, and others). Furthermore, the professional diversity of our program has always, in my mind, been one of the program's assets, even though trying to teach informatics simultaneously to a physician, nurse, computer scientist, and businessperson can be a challenge!

But it nonetheless has been gratifying to see many physicians go on to assume roles and leadership in the field. The diverse roles that physicians who enter the field take exemplifies the expansion of these roles.

There are a number of issues ahead for physicians contemplating careers in informatics to ponder. One concerns training. How much should they seek? Should they get it at all? If they do, in what kinds of programs should they train? I honestly cannot give an unequivocal answer. There are many physicians who move into informatics roles without any formal training. However, I do believe over time that formal training will be a requisite for informatics jobs. If nothing else, one's competitors for those jobs will have such training.

As for how much training, that is also an uncertainty. There is a growing recognized knowledge base for the informatics field. There is also recognition of an increasing number of best practices. Physician-informaticians might not need to understand all the technical details of the systems with which they work, but they must have the big picture both of the technology and how it fits into their environment.

Another issue on the horizon for physicians is certification, in particular the proposed clinical informatics subspecialty. This subspecialty will be available to physicians in many, perhaps all, specialties (e.g., internal medicine, pediatrics, family medicine, surgery, etc.). There are still many unknowns about this process, such as how will other informatics experience and training besides formal on-site fellowship training be viewed and how physicians without board certification might be able to take part. Nonetheless, certification is important in healthcare professions, and certification in informatics will lead to more professional recognition of the field.

I believe it is safe to conclude here are tremendous opportunities for physicians to be innovators and leaders in the proper and most effective use of information technology IT) not only in healthcare, but also personal health, public health, and research.

Despite the uncertainty about some of the details, the outlook for physicians in informatics is bright, even after the initial wave of EHR adoption is complete (as addressed in a previous blog entry). The need for expertise in health IT implementation will only increase, especially as we see more coordination and quality measurement of care delivery.

A Teachable Moment About Healthcare Reform and Markets

2010-10-12T05:43:00.000-07:00

This is not a political blog, and I prefer to keep the postings focused on biomedical and health informatics. However, as an educator, I sometimes feel compelled to do some educating to remind people in a debate where there are some substantial misperceptions. I believe this to be in the case in the healthcare reform debate. While I do recognize there are different positions on the solutions to the problem, I disagree that there is not a factual basis upon which to base the discussion. One of my favorite quotes in life comes from the late Sen. Daniel Patrick Moynihan, who stated, "Everyone is entitled to his own opinion, but not his own facts."

I certainly have my opinions on how healthcare should be reformed in the United States, but I will have those debates elsewhere. I do, however, believe we need to get the facts straight. To that end, I had an Op-Ed column published in this week's Oregonian newspaper. The text is reproduced below. I do not have much optimism that this piece can alter the substance or tone of what passes for our political debate, but I do hope that it might cause some to think.
_____________________________________

Last week's article in The Oregonian about health care costs varying widely by hospital was hardly surprising to anyone familiar with the health care "marketplace." The problem with health care is that it doesn't obey the principles of markets, and the problem is unlikely to be fixed by letting the market work.

Before we even think about pricing of health care items, we must first remember that Americans don't commonly purchase health care. Rather, we purchase health insurance. Only the very rich, and certainly not the upper middle class or anyone less wealthy, could afford to buy health care on a per-item basis. Instead, we buy insurance, which means that the ability to afford substantial medical expenses will be possible if and when we need it. Naturally, we hope we remain healthy and don't need it.

Because we buy insurance and not care, we need to think about health care purchasing in terms of setting reasonable prices that large-volume insurers, including federal and state governments, can negotiate. Those opposed to health care reform proclaim that people should not be forced to buy insurance "they don't need." But buying something we hope we'll not need is the whole idea behind insurance. If we all pay something for insurance, then we spread the risk for those with truly high expenses. If we let people wait until they get sick to buy insurance, we defeat the purpose of insurance. That's one of the reasons why it's essential that young, healthy people be required to purchase health insurance.

We also need to think differently about "rationing" of health care, giving up the notion that it should never occur. As most free-market economists will tell you, rationing is a good thing. Rationing is the means by which free markets work, determining, for example, whether we can afford a particular house, or car or computer. So the issue is not whether to ration health care, but rather how will we go about doing it, either through the purely free market or by some mechanism that attempts to maximize the allocation of health care resources to achieve the greatest common good. Saying that all health care decisions must be made between a patient and his or her physician is not an answer, since such a system is not economically sustainable and provides no mechanism to achieve any kind of rationing, even rationing by purely market mechanisms.

There are other aspects of the health care marketplace that we must remember when thinking about the price of care. When it comes to acute illness, few people are in the position to comparison shop on price, quality or anything else. If you suffer serious trauma or an acute life-threatening event, such as a heart attack, you generally go to the nearest hospital. Even if your illness is less acute and you can take time to make a decision, our health care system doesn't have the ability to provide information that would enable you to make truly informed decisions about quality or cost. Reputation and anecdotes about hospitals and clinicians are only that, and do not provide details on quality and skill. Furthermore, few patients are willing to go against the advice of their physician when recommendations for tests and/or treatments are given. There is truly little to keep people from spending money that the health care system wants them to spend.

And the system wants people to spend in a big way.

One of the most notorious examples of that is pharmaceutical companies. While these companies have created truly life-saving products over the years, they're also effective at creating medical conditions or advocating for prescribing of their products that people don't necessarily need. Even physicians sometimes have incentives to advocate for tests and treatments that patients truly don't need. There are too many entrenched self-interests in the health care system, which sometimes even piggyback on to "reform" efforts.

Some advocate for putting more financial burden on consumers through higher deductibles and co-pays, thus leading them to consider the cost of their care. While I'm not opposed to making consumers more cognizant of the cost of their care, the problem with this approach is that while individual people may have leverage with a physician practice, they have little if any leverage with hospitals or pharmaceutical companies. Another problem with increasing out-of-pocket health care costs is that consumers might be inclined to forgo screening or other preventive care that could reduce costs in the long run -- for example a colonoscopy that detects colon cancer at a very early stage when it's cheaper to treat.

Once we abandon the notion that markets will cure runaway health care costs, we can then work our way toward a meaningful conversation about costs and the role of government, insurers and others. It's unfortunate that this discussion has become so political and ideological, if not emotional, preventing us from having rational dialogue about the role of various participants in the system, including first and foremost the patient.

New Data Reiterates Coming Need for Health IT Workforce

2010-10-07T15:22:00.000-07:00

A recent survey from the College of Healthcare Information Management Executives (CHIME) provides additional data on the growing need for a skilled health IT workforce, with a particular need in "clinical software implementation and support staff." The survey was administered to healthcare CIOs in September, 2010 and had 182 respondents, representing 13% of CHIME's membership. A summary and full report of the survey are available.

The respondents came from a variety of hospital types and sizes, from large academic centers to small community hospitals. Interesting enough, the biggest needs, more than 20% staff shortages, were found at the big and small institution ends of the spectrum.

The highest proportion of open positions, as noted above, were in clinical software implementation and support staff, with 71% of CIOs reporting openings. The types of positions open included project managers, analysts, application coordinators, report writers, trainers, informatics staff, and technical staff. I really consider all of these positions to be in the realm of "informatics," or at least are positions for which informatics training would prepare one well.

One disappointing finding of the survey was half of the respondents reporting that they did not foresee additional spending on bolstering IT staff. On the other hand, most of the those organizations will be seeking their "meaningful use" incentive dollars, so hopefully their leadership can be convinced to invest in staff.

Healthcare organizations are not the only ones with needs and who are hiring. The EHR vendor Meditech reported that it will be hiring over 800 people in a new facility in Massachusetts. (Note to Oregon economic development leaders: There is opportunity for job creation in this field!)

These data are very consistent with a survey reported by HIMSS last spring, which had a total of 149 respondents. The survey found that 86% of organizations planned to hire additional IT staff in 2010. The areas respondents would most likely hire included implementation support specialists (55%), implementation managers (51%), and technical support (48%). The highest ranked area that organizations felt they lacked qualified candidates was clinical informatics (30%), followed by implementation expert (26%) and software maintenance expert (17%).

Finally, the consulting firm CSC, whose web site of reports on various aspects of meaningful use is one of my favorites, has produced a report on HIT workforce shortages. They summarize the research (including my study that used HIMSS Analytics data), describe the ONC workforce development programs, and discuss the implications to healthcare organizations. The latter include competition for qualified staff, inexperience among those newly trained, leading to lack of those with enough experience to assume leadership roles, attrition, and competition from other HIT tasks, such as ICD-10 implementation, HIPAA issues, and insurance exchanges.

The report's recommendations for overcoming these challenges is "expand, retain, and exploit," i.e., training and developing from within as well as exploring alternatives from outside the organization.

Of course, my advice is to hang tight, and hopefully the graduates from the newly funded ONC workforce development programs, including ours at OHSU, will start to fill the need soon.

New Talk and Department Web Site

2010-09-30T15:51:00.000-07:00

This week I had the opportunity to kick off our OHSU Biomedical Informatics Conference Series that takes place on Thursdays at 11:30 am. I presented an overview of the HITECH program, OHSU's role in it, and how it impacts not only clinical informatics, but other areas of informatics as well, such as bioinformatics, clinical research informatics, public health informatics, and consumer health informatics. A video of the talk and PDF of my slides (with references) are available.

We also launched our new department web site this week. All of our old URLs still work, including those to the site and to information about our ONC scholarship funding.

Two New Articles Add Perspective For Informatics in 21st Century Healthcare

2010-09-27T21:35:00.000-07:00

A couple new articles in medical journals give some added perspective for the direction of biomedical informatics and its role in healthcare. The articles are physician-oriented but could easily be applied to other healthcare professionals or for that matter patients, consumers, and researchers.

The first was published on-line ahead of print in Academic Medicine and authored by Bill Stead of Vanderbilt University and four colleagues. The main thesis of this paper is that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains." The authors note that the numbers of facts per clinical decision will increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.). While I would argue whether genomics has yet had much impact in clinical medicine, I do acknowledge that just the complexity of our clinical knowledge of diseases, tests, and treatments is already overwhelming what Stead and colleagues call the "human cognitive capacity." When you factor in the social and economic complexity of our healthcare system, you do not even need genomics to make it exceedingly complicated, even though genomics is likely to make it more so.

These authors also note the consensus developing around the core competencies for the biomedical informatics field being developed by the AMIA Academic Forum. One particularly valuable exercise of this paper is to map the key competencies to the six core competencies for future health professionals first enumerated by the Accreditation Council for Graduate Medical Education (ACGME).

The authors envision a central role for academic health centers (AHCs), recommending advancement in four areas (to quote):

Create academic units in biomedical informatics
Adapt the IT infrastructure of AHCs into testing laboratories
Introduce medical educators to biomedical informatics sufficiently for them to model its use
Retrain faculty in AHCs to lead the transformation to health care based on a new systems approach enabled by biomedical informatics

Indeed, these activities could be an instance of the Health Innovation Zones that the Association of American Medical Colleges calls for AHCs to become.

The authors state that "embracing this collective and informatics-enhanced future of medicine will provide opportunities to advance education, patient care, and biomedical science."

The second paper is a commentary by Ted Shortliffe of AMIA in JAMA. This piece appears in the annual special issue of JAMA to devoted to medical education. As such, it focuses on medical education and has a central thesis that the focus of medical practice is as much information as it is patients. Yet while medical education goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort at obtaining, using, and analyzing information.

Shortliffe notes that biomedical informatics should be a discipline fundamental to medical education, focusing on both its practical application and core fundamental concepts. He points to a number of examples of where medical practice could benefit from informatics. Few students, he note, are skilled at searching. While anyone in the world can do a Google search, most medical students are not able to skillfully use the myriad of search systems available, from PubMed to the clinically oriented genomics databases. Likewise, few students have mastery of using an electronic health record, let alone make critical secondary use of its data for quality improvement, patient empowerment, or clinical research. I suspect that a paucity of medical students understand the full ramifications of privacy and security, health information exchange, or other informatics topics that will impact their practices in a large way in the coming decades.

One detractor of teaching more informatics to medical students at OHSU used to argue that today's students have no need for such instruction, since they are digital natives, proficient in email, social networking applications, and smart phone usage. Yet these technologies are not informatics, which Shortliffe pulls from the AMIA core competencies definition as "the interdisciplinary, scientific field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making motivated by efforts to improve human health."

I hope these articles are widely read and acted upon by healthcare leaders, educators, and forward-looking practitioners.

Welcoming Unprecedented Numbers to the OHSU Informatics Educational Program

2010-09-24T11:04:00.000-07:00

The beginning of the academic year is always an exciting time, and this year is exceptionally exciting, due to the unprecedented enrollment in our program. While numbers do not tell the entire story, they clearly show a field in ascension. While much of the growth is fueled by our University-Based Training (UBT) Grant from the Office of the National Coordinator for Health IT (ONC), there is growth in all areas of our program.

This week we welcomed an total of 95 new students to the OHSU biomedical informatics graduate program. This matriculating class includes 4 PhD, 25 Master's, and 66 Graduate Certificate students. Of the 25 Master's students, 19 are in the clinical informatics track and 6 are in the bioinformatics and computational biology track. Of the 19 in the clinical informatics track, 10 are on-campus and 9 are distance-learning students. Of the 10 on-campus master's students, 8 are funded by our new ONC UBT grant. All of the Graduate Certificate students are distance-learning students, with 36 funded by the UBT grant.

These new students bring our total student body to approximately 350 students who are actively enrolled in the program. This includes 15 PhD, 83 Master's, and approximately 250 Graduate Certificate students. The 8 Master's and 36 Graduate Certificate students starting the UBT program join 12 other Graduate Certificate students who started in the summer quarter. This brings our total UBT enrollment to 56 students. Applications are now being accepted for those who wish to apply for Graduate Certificate UBT funding starting in the winter quarter. We are well on our way to educating 148 students over three years in the UBT grant.

All of these students will aspire to join our alumni, which consists of 272 people who have received 281 degrees, certificates, and fellowships (as of June, 2010). Our program has awarded 5 PhD, 63 Master of Science, and 74 Master of Biomedical Informatics degrees. We have also awarded 120 Graduate Certificates. Many of these alumni work in a variety of health care, industry, academic, and other settings.

I suppose I am biased, but I am incredibly optimistic for the future of biomedical informatics education. This field is truly establishing an identity as leading the charge to improve health, healthcare, biomedical research, and public health through better use of information. This involves not only electronic health records, but also other information systems in areas such as genomics, telemedicine, knowledge management, and clinical and translational research. Because of this, I am confident that our current students will find many rewarding career opportunities in all of these areas. I am also certain that informatics education will continue to be appealing long after the ONC funding ends, as students will be attracted to careers in this growing field in the long run.

Addendum

For those who better visualize numbers in a more tabular form, here is a summary (sorry Blogspot does not allow multiple levels of indenting):

Matriculating class, Fall, 2010 - 95
-PhD -4
-Master's - 25
--6 Bioinformatics Track
--19 Clinical Informatics Track
---10 on-campus (8 UBT)
---9 distance learning
-Graduate Certificate - 66
--(36 UBT)

Total enrollment - about 350
-PhD - 15
-Master's - 83
--60 distance learning
--23 on-campus
-Graduate Certificate - about 250

Alumni (as of June, 2010)
-People - 272
-Fellowships only - 19
-Degrees - 262
--PhD - 5 (2-3 more just about done)
--Master's - 137
---Master of Science - 63
---Master of Biomedical Informatics - 74
--Graduate Certificate - 120

Will There Be a Need for Informaticians After EHR Implementation? Yes!

2010-09-12T02:22:00.000-07:00

A question I am asked from time to time is whether there will be a need for informaticians once we are "done" implementing electronic health records (EHRs). My reply is that implementing EHRs is only a beginning, and actually not the most interesting part. Much more important is what we do with those EHRs and other information systems after they are implemented.

Once EHRs are implemented, there will still be all sorts of "meaningful" things that need to be done with them, and I am not just talking about the meaningful use guidelines, though those will keep us busy well past the middle of this decade. (Even the Office of the National Coordinator for Health IT [ONC] believes it unlikely that most eligible professionals and hospitals will achieve Stage 3 meaningful use before 2018-2019.)

But I only see healthcare becoming more data-driven in the future, with increasing emphasis on managing information to provide safe and less costly care. Activities such as quality measurement and improvement, improving efficiency, dealing with new types of information, and continued advances in information technology (IT) are likely to keep us busy for a long time to come.

One insight to these future needs comes from a new article by Bill Stead and colleagues (Academic Medicine, 2010, Epub ahead of print). It is unfortunate that this article is published in a journal that requires an individual or institutional subscription to access it, because it presents a clear picture that the complexity of information required to practice medicine is increasing and that clinicians - and the educators who train them - must learn how to function in the increasingly "information-rich" healthcare environment.

This article also lists a number of key competencies in informatics for physicians, organizing them within the framework Accreditation Council for Graduate Medical Education (ACGME) core competencies for physicians. The article also recommends that informatics become a foundational science for healthcare, advocating development of academic units involved in academic and operational activities, using the IT infrastructure of academic health centers as testing laboratories, and retraining faculty to lead the transformation of healthcare through the use of informatics.

There are many other reasons why informatics will not cease to be important once there are EHRs on every desk in healthcare. As us baby boomers age and develop more health problems, we will likely want to manage our healthcare the way we manage many other things in life (e.g., banking, air travel, buying certain things such as books, etc.), which is on-line. We also know that there is still plenty of room for improvement with existing EHRs. Data entry is too time-consuming, poor interfaces can hide critical data, and we still need much smoother interoperability, especially of data. The ONC SHARP program acknowledges the need for continued research in the four areas it is funding: architecture, privacy and security, secondary use of data, and cognitive-centered computing.

In essence, the implementation of EHRs enables a whole host of other activities that will allow improvement of health, healthcare, public health, and biomedical research. As such, there will only be increased demand for informaticians to perform and lead these activities.

More Information Available on Meaningful Use

2010-08-27T16:28:00.000-07:00

In my initial post on the final rules for meaningful use, I mentioned a number of other resources to describe the rules. Since last month, a number of other new readable sources of information have appeared.

Dr. Blumenthal's overview of HITECH in the New England Journal of Medicine has been officially published.

Readers of this blog know of my enthusiasm for the Geek Doctor, HITECH Answers, and Mr. HIStalk sites, but another source of information on meaningful use I value highly is Computer Sciences Corp.. They have not only issued "updates" on a variety of topics, including meaningful use, certification, and others, but also have established a Meaningful Use Community.

The Health Affairs blog has a post by the Obama Administration's two major leaders for health IT, Drs. Blumenthal and Berwick.

Another interesting post in that blog comes from Kevin Weiss and Sheldon Horowitz of the American Board of Medical Specialties. They note that the five healthcare goals for meaningful use overlap significantly with the six core competencies for physician maintenance of certification developed several years ago. They advocate that the meaningful use goals be aligned with maintenance of certification for physicians. I would agree that being able to use information and IT systems is an essential skill for the 21st-century physician (or any healthcare professional for that matter, and even for patients, researchers, policy makers, and others).

Naturally, during a monumental time like this, there are some express concerns. As typically happens, some argue the adoption of EHRs is moving too fast (American Hospital Association, Huffington Post Investigative Fund, and the Washington Times [the full breadth of the political spectrum!]) while others advocate it is moving too slow (The Leapfrog Group).

I maintain that no one really knows the right pace to move forward. We need to maintain flexibility, adjusting our plans when necessary. But inaction is not an option either. I do agree this has elements of a grand experiment whose outcome we will know only many years, lives, and dollars from now. But just as a I feel about healthcare reform, the status quo is not tenable, and action is required. Translating ideals among competing financial and other interests is always a messy task, but it is not reason for inaction.

Update on ONC workforce projects

2010-08-02T16:45:00.000-07:00

Although summer is historically "down time" in academia, this summer has been anything but down. Like many people in the health IT arena, I have been busy with our Office of the National Coordinator for Health IT (ONC)-related projects, taking advantage of what colleague Paul Tang calls the "opportunity of a generation." In this post, I thought I would take the opportunity to provide an update on the ONC workforce development programs in which OHSU is heavily involved.

As I reported in April, OHSU received grants in two of the four workforce programs. One of the programs in which we received a grant is part of three interrelated programs. These programs collectively aim to rapidly build the front-line workforce to achieve the EHR adoption goals of the HITECH legislation. The project OHSU is involved in is the Curriculum Development Centers Program, where five universities (OHSU, Columbia, Duke, Johns Hopkins, and UAB) are developing instructional materials for another program, the Community College Consortia to Educate Health Information Technology Professionals Program. The latter program is funding five regional consortia to deliver short-term six-month certificate programs that focus on six workforce roles that ONC envisions as required to achieve the HITECH agenda. About 80-85 community colleges are in the five regional consortia, all of whom are developing short-term certificate programs around the workforce roles, which will commence this fall.

Since literally the day the grant was awarded, the curriculum development centers have been hard at work, first planning and now implementing the first version of the instructional materials. (Two additional versions of the curriculum will follow on during the two years of the project.) The five universities are each developing four "components," which are roughly equivalent to semester-long courses, for a total of 20. Each community college will free to use all, some, or none of the instructional materials we are developing. ONC has designated a "set table" of these components for six workforce roles to which the community college certificate programs will teach.

The OHSU Curriculum Development Center is further designated as the National Training and Dissemination Center (NTDC). We have the additional tasks of training the community college in the use of the materials and developing a dissemination Web site to host them and collect feedback. A major part of the training task will be a training event that will be held next week (August 9-11) in Portland. About 250 community college faculty will attend the event to receive training in the use of the materials. The event will also feature other sessions on education-related issues, such as implementing distance learning in health IT and how to manage classes that comprise students with it backgrounds and students with healthcare backgrounds.

The dissemination Web site will host the materials that all community college faculty from the 80-85 community college partners can access. They will be able to use the materials "out of the box" or mix and match pieces of them with other curricula at their institutions. All of the materials are distance learning-oriented, not only slides and lesson plans but also voice-over-slide narrations.

Another project that the Curriculum Development Centers project touches on is the Competency Examination for Individuals Completing Non-Degree Training Program, which will assess the competencies attained by graduates in the community college programs for the six workforce roles.

OHSU is also involved in the fourth and final workforce development program, the University-Based Training (UBT) Program. This program will fund longer (but still short-term) study in six additional workforce roles in university settings. OHSU is one of nine universities or consortia thereof (OHSU, Colorado, Columbia, Duke, George Washington, Indiana, Johns Hopkins, Minnesota, and Texas Tech) that will be using the grant to subsidize students in Type 1 (less than one year) and Type 2 (1-2 year) programs.

OHSU is implementing the UBT grant as a source of financial aid for our existing graduate programs. More information can be found on our web site, which has a new redirection URL, www.informatics-scholarship.info. Type 1 students are funded to complete our Graduate Certificate Program in one year, while Type 2 students will be funded to complete the Master of Biomedical Informatics (MBI) program in 18 months of full-time study. As OHSU is on an academic quarter system, with four quarters of equal length, Type 1 students will need to take an average of two classes per quarter to complete the program in one year. This is more than the typical student in the program who works full-time and would find more than one course at a time challenging. The MBI program requires 52 credits, with 46 in courses (about 16 three-credit courses) and six in a capstone project. To do the MBI in 18 months will require full-time enrollment over six consecutive quarters. While the regular MBI program can be done on-line (with students required to complete two on-campus short courses during their studies), ONC-funded students will need to be on-campus students.

The OHSU UBT grant will allow 135 Graduate Certificate and 13 MBI students to be funded over three years. We have completed two cycles of applications already for the certificate program and one for the master's program. Twelve students started the certificate program in the summer term. We have also offered funding to 41 certificate and 8 master's students to start in the fall. Another round of certificate program applications will take place in the fall for admission in the winter quarter and continue every quarter until the funding is exhausted. A second round of master's degree applications will take place for the fall of 2011.

We are also adding other features to the program for ONC-funded students. They will be required to do a practicum (certificate students, one quarter) or internship (MBI students, 2-3 quarters, and can comprise the capstone project if accompanied by a write-up). Distance students will be required to arrange their own practicum experiences, with our guidance. We are working with healthcare organizations, industry, regional extension centers, and others to make these experiences available. We are also putting in place a career counseling service for these students.

Now that the final rules for meaningful use are out, the state health information exchanges and regional extension centers are being launched, research and demonstration are funded by the SHARP and Beacon programs respectively, and the academic programs for workforce development are starting up, all of the major pieces of HITECH are in place. The grand experiment is beginning! Projects like this never quite turn out as you expect, but I am certain that healthcare will be better from all of this, and I am quite confident that a more robust educational infrastructure will emerge from the workforce development programs.

Core competencies of meaningful use for people, organizations, and systems

2010-07-30T19:17:00.000-07:00

As an educator, I often think of competencies, which are the knowledge, skills, and attitudes we hope that students obtain from the education we deliver. As I think about competencies related to meaningful use (MU), I see that there are competencies not only that people must have, but also organizations and even the information systems they are deploying. The final MU rules make it clear that there are a number of competencies that people, organizations, and systems must have to succeed with the HITECH agenda.

The list of MU criteria and what must be done to implement them are a veritable textbook of clinical informatics. They also include some additional competencies from other sub-areas of biomedical and health informatics as well.

Clearly the major competency area for MU is clinical informatics. Individuals, their organizations, and their information systems must have a thorough understanding of most of the tenets of clinical informatics. A list of what competencies are needed and why includes the following:

Clinical data, e.g., demographics, vital signs, problem lists, medications, structured data, advance directives
Clinical decision support - rules, drug-drug and related checks, medication reconciliation
Computerized provider order entry
Health information exchange
Privacy and security
Healthcare quality
Organizational and project management
Standards and interoperability - e.g., HL7, ICD-9, SNOMED, LOINC, CCR/CCD, etc.

Of course, MU is not limited to clinical informatics. People, organizations, and systems must understand elements of public health informatics, since of the "menu" criteria must include the exchange of information with state or local public health agencies. Likewise, these entities must have competence in consumer health informatics, understanding the ramifications of the requirements to provide patients with summaries of their care and, in the long run, exchange information with personally controlled health records.

There are more competencies that one must have across for all uses of health information technology and the even-larger field of biomedical and health informatics. Nonetheless, competency in MU is something that all people, organizations, and systems that deal with health must know about. Many must master it, not only to achieve the short-term objectives and funding of HITECH, but also to provide a patient-centered, evidence-based, and cost-effective healthcare system for the 21st century.

Meaningful Use Rules Finalized!

2010-07-20T07:23:00.000-07:00

July 13, 2010 was, at least for those of us in the informatics field, a historic day: the release of the Stage 1 meaningful use rules by the Office of the National Coordinator for Health IT (ONC) and the Center for Medicare and Medicaid Services (CMS). These rules define explicitly what healthcare professionals and hospitals must do to quality for the incentive funding under the HITECH Act. As I have written before, the meaningful use framework is an excellent construct, enshrining the notion that HITECH is not just about adopting technology, but rather insuring it gets used in ways that benefit human health. As much as we love technology, we can never lose sight of the notion that, at least in healthcare, the goal of its use is to improve the care that people get. We do not always succeed at that, but it should always be what motivates us.

The final rules also demonstrate some other positive attributes about people, organizations, and governments. Most critical of these was that ONC and CMS listened, recognizing that the initial proposed rules were a little too much, too soon. So they dialed back, but not to the point of making the criteria too easy, which could have effectively turned the program into a government boondoggle, i.e., a subsidy for healthcare organizations. The whole ONC process has been very open and deliberate, involving many thoughtful people and organizations.

So what do the rules actually say? Before we get into the details, let's step back and look at the big picture. It is estimated that if every eligible professional and hospital meets the criteria, the cost of the program will be about $27 billion. When you add in the additional $2 billion invested in infrastructure (regional extension centers, HIE funding for the states, SHARP research projects, Beacon demonstration projects, and workforce development), the total cost will be $29 billion. That is no small sum of money, but is one of the those situations where the market would be unlikely to bring about this change. True to the American Recovery and Reinvestment Act (ARRA) from where it was legislated, the program certainly has created jobs and will likely create more.

As always with health IT, you can find a great deal information about the rules on the Web. One place to start, especially if you have a lot of time on your hands, is the full text of the final meaningful use rule (officially called the CMS Electronic Health Record Incentive Program, which also has an official Web site) and the final standards rule (officially called the Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology). However, for those of us with other things to do than read federal rules documents hundreds of pages long, concise early summaries are available from a number of places, including:

An article in New England Journal of Medicine (NEJM) by Dr. David Blumenthal, National Coordinator
Postings by Dr. John Halamka (Geek Doctor) on the meaningful use and standards rules, along with the beginnings of a frequently asked questions (FAQ) list
A succinct overview from the Mr. HISTalk blog

The overall requirements from the ARRA legislation are of course still intact. The overall requirements for meaningful use involve:

Use certified EHR technology in a meaningful manner
Use certified EHR technology connected in a manner that provides for health information exchange to improve the quality of care
Using certified EHR technology, the provider submits information on clinical quality measures

A certified EHR is a qualified EHR approved by an ONC- recognized certifying body. A qualified EHR is an electronic record of health-related information on an individual that includes patient demographic and clinical health information, such as medical history and problem lists and has the capacity to:

Provide clinical decision support
Support physician order entry
Capture and query information relevant to healthcare quality
Exchange electronic health information with, and integrate such information from, other sources

The incentives will be provided through increased Medicare or Medicaid reimbursement to eligible professionals (EPs), who include:

Medicare: Physicians, Osteopathic Physicians, Dentists, Podiatrists, Optometrists, Chiropractors
Medicaid: Physicians, Pediatricians, Dentists, Certified Nurse Midwives, Nurse Practitioners, Physician Assistants operating at an FQHC/RHC

As well as to eligible hospitals (EHs), which include:

Medicare: hospitals paid under inpatient prospective payment system, critical acess hospitals; within the 50 states or DC
Medicaid: acute care hospitals, childrens' hospitals

What follows is an overview of the criteria required to achieve meaningful use in Stage 1. The text that follows is gleaned most verbatim from Dr. Blumenthal's NEJM article as well as two PDF tables sent by email (can't find them on the Web) by ONC from the final regulations with the criteria sorted by core and menu items and by method of measure. An additional table from ONC compares the preliminary and final rules.

The rules are now organized so that in order to achieve meaningful use, an EP or EH must achieve 14 (EH) or 15 (EP) core rules and then five additional menu rules. There are also some additional twists on the menu rule. For example, some of them apply only to EPs while others apply only to EHs. In addition, one of the menu items selected must be a public health measure. This means that EPs must submit data to an immunization registry or syndromic surveillance registry, while EHs must submit to either of these or a reportable lab registry. However, if a state or regional public health agency is not prepared to accept such data, the EP or EH will not be penalized.

The 14-15 core measures must be achieved by all EPs and EHs in order to qualify for incentive payments. These include:

Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause of death in the event of mortality) data - More than 50% of patients’ demographic data recorded as structured
Record vital signs and chart changes (height, weight, blood pressure, body - mass index, growth charts for children) - More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data
Maintain up-to-date problem list of current and active diagnoses - More than 80% of patients have at least one entry recorded as structured data
Maintain active medication list - More than 80% of patients have at least one entry recorded as structured data
Maintain active medication allergy list - More than 80% of patients have at least one entry recorded as structured data
Record smoking status for patients 13 years of age or older - More than 50% of patients 13 years of age or older have smoking status recorded as structured data
For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request - Clinical summaries provided to patients for more than 50% of all office visits within 3 business days; more than 50% of all patients who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it
On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, and for hospitals, discharge summary and procedures) - More than 50% of requesting patients receive electronic copy within 3 business days
Generate and transmit permissible prescriptions electronically (does not apply to hospitals) - More than 40% are transmitted electronically using certified EHR technology
Computer provider order entry (CPOE) for medication orders - More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE
Implement drug-drug and drug-allergy interaction checks - Functionality is enabled for these checks for the entire reporting period
Implement capability to electronically exchange key clinical information among providers and patient-authorized entities - Perform at least one test of EHR’s capacity to electronically exchange information
Implement one clinical decision support rule and ability to track compliance with the rule - One clinical decision support rule implemented
Implement systems to protect privacy and security of patient data in the EHR - Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies
Report clinical quality measures to CMS or states - For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures

EPs and EHs must then select any five choices from the menu set. Criteria applicable to both EPs and EHs include:

Implement drug formulary checks - Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period
Incorporate clinical laboratory test results into EHRs as structured data - More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach - Generate at least one listing of patients with a specific condition
Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate - More than 10% of patients are provided patient-specific education resources
Perform medication reconciliation between care settings - Medication reconciliation is performed for more than 50% of transitions of care
Provide summary of care record for patients referred or transitioned to another provider or setting - Summary of care record is provided for more than 50% of patient transitions or referrals
Submit electronic immunization data to immunization registries or immunization information systems - Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions)
Submit electronic syndromic surveillance data to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional menu criteria for EHs include:

Record advance directives for patients 65 years of age or older - More than 50% of patients 65 years of age or older have an indication of an advance directive status recorded
Submit of electronic data on reportable laboratory results to public health agencies - Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

Additional criteria for EPs include:

Send reminders to patients (per patient preference) for preventive and follow - up care - More than 20% or patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders
Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) - More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

In my postings ahead, I will explore the meaningful use criteria in more detail, especially from the standpoint of the competencies requires of informatics users, organizations, and systems.

Where Are the Jobs? Read While You Wait

2010-07-09T04:20:00.000-07:00

As readers of this blog know, I am bullish about careers in informatics and the optimal training to acquire and perform them successfully. Increasingly I am asked, where are the jobs? Or a variant, which is, why are the jobs not more plentiful, especially with all the funding coming from HITECH?

My answer to these questions is, just wait! We are all waiting for the final "meaningful use" rules, which are supposedly set to be released next week. Once they do, hospitals and clinical practices will have a clear picture of what they need to do to quality for the electronic health record (EHR) adoption incentives and make their implementation (and hiring) plans accordingly. But until the final rules are set in stone, most are taking a wait-and-see attitude. Some organizations are not waiting, while others predict a strong upcoming need for consultants.

In the meantime, there are plenty of places to look for jobs. Probably the best sources are the various "job mines," both those from informatics/IT organizations, such as AMIA, AHIMA, or HIMSS, as well as health IT publications, such as Healthcare IT News and Healthcare Informatics. For physicians, a list of Chief Medical Information/Informatics Officer (CMIO) can be found on the AMDIS Web site.

Speaking of jobs and the workforce, I have also published a substantially updated version of my review of health IT workforce research in the journal Applied Clinical Informatics. The article not only reports all of the latest research I am aware of, but also analyzes the data according to five themes: quantities and staffing ratios, job roles, gaps and growth, leadership qualifications, and education and competencies. There is still much we do not know, and no one can truly predict the impact of programs like HITECH.

I am also delighted to have discovered an interesting and comprehensive new resource about the HITECH program called HITECH Answers. They have even asked me to serve as one of their resident experts, and will be publishing excerpts from this blog.

In the meantime, those wanting to learn more about the field can always enroll in the next offering of the OHSU-AMIA 10x10 course, which begins around July 20, 2010. I will no doubt be furiously updating some of my materials when the final meaningful use criteria are released.

What Others in the Community are Saying About the ONC HIT Workforce Program

2010-06-10T08:51:00.000-07:00

Some articles by Joe Conn of Modern Healthcare on the ONC Workforce Development Program:

There has also been a press release and more detailed information from AMIA on the breadth of its member involvement in all of the ONC funded programs.

Meaningful Use: A Highly Useful Construct for Informatics

2010-05-23T07:13:00.000-07:00

Whatever does happen with the ARRA/HITECH programs in the long run, one value to come out of the entire process is the construct of "meaningful use." In the next month or two, we will hear how meaningful use is operationalized in its first (2011) stage. Two more stages will follow in 2013 and 2015, and later in this decade we will know if the meaningful use of the electronic health record (EHR) has improved healthcare and people's health.

But I must give credit to whoever "invented" the construct of meaningful use. It is a brilliant way to think about the implementation of health information technology. I would also argue that it drives home the distinction between informatics and information technology (IT) that I have written about elsewhere, with the former focused on the goal of making "meaningful use" of the technology of the latter.

I have been asking around to see to whom we can attribute the invention of meaningful use. I will stand corrected if I find out the term was used before this, but it appears that it was first coined in a bill introduced in the 2007-2008 Congress, H.R. 6898: Health-e Information Technology Act of 2008. The bill was never passed but proposed the idea of "incentive payments to physicians and inpatient hospitals that meaningfully use a certified health information technology system." HR 6898 was introduced by Pete Stark, and has much verbiage from what eventually went into ARRA/HITECH. (Given the meaning that Stark’s name has in other contexts, it is indeed interesting that he could have been associated with the origination of the term!)

The idea behind meaningful use is simple: The goal is not to merely put computers and EHRs in physician's offices and in hospitals, but rather to make sure that they are implemented in ways that improve individual and population health. As HITECH has been operationalized, there are five underlying goals for meaningful use:

Improve quality, safety and efficiency
Engage patients in their care
Increase coordination of care
Improve the health status of the population
Ensure privacy and security

Every specific criteria that HITECH requires physicians and/or hospitals to do in order to get EHR adoption incentive funds must be tied back to one of these goals. For example, they must implement decision support rules, which are tied back to the goal of improving quality, safety, and/or efficiency of care. Likewise, they must provide care summaries in the patient's format of choice, tying back to the goal of engaging patients in their care. In the matrix of proposed criteria for meaningful use accompanying the Notice of Proposed Rule-Making (NPRM), every last criteria is tied back to one of the five goals listed above.

The definition is further modified that certified EHR technology be used, and that these certified EHRs be connected for health information exchange and able to submit information on quality measures, but that is just a modifier to the core construct. In the weeks and months ahead, we will see meaningful use operationalized, but I hope that we do not lose sight of how excellent of a construct it is for thinking about the value of HIT.

ONC-Funded Scholarship Program for OHSU Biomedical Informatics Graduate Program Open for Applications

2010-05-15T05:05:00.000-07:00

Applications are now being accepted for scholarship funding from the Office of the National Coordinator for Health IT (ONC) to study in the Oregon Health & Science University (OHSU) biomedical informatics graduate program. This funding comes from the ONC's University-Based Training Program, and is part of their Health IT Workforce Development Program that aims to rapidly expand the workforce through predominantly short-term educational opportunities. In the case of OHSU, this will involve tuition scholarships for 135 students in our Graduate Certificate program and 13 students in our Master of Biomedical Informatics (MBI) program over the next three years. The latter will also receive a stipend and student health insurance while enrolled in the program. Enrollment for both programs will begin in Fall 2009.

Despite this funding, very little else about OHSU's larger informatics programs will change. The ONC scholarships add funding for a large number of students as well as some additional academic requirements centered around six health IT job roles. Each of these job roles has requirements for additional courses that either already exist or will shortly be added to the curriculum. Students not funded by the ONC scholarships will still be able to study in the program as they always have. For more information, click on the "ad" to the right or go directly to www.ohsuscholarships.info.

More details about the program are available on the OHSU Department of Medical Informatics and Clinical Epidemiology (DMICE) Web site. To qualify for funding, students must be US citizens or permanent residents; must not have been enrolled in an informatics educational program on December 17, 2009 or earlier; must commit to study in one of six ONC-designated job roles; and must commit to completing the Graduate Certificate program in one year or the MBI program full-time and on-campus over 1 1/2 years.

The OHSU Biomedical Informatics Graduate Program offers a variety of certificates and degrees in three tracks: clinical informatics (CI), bioinformatics and computational biology (BCB), and health information management (HIM). The CI and HIM tracks are focused on the healthcare and public health arenas, while the BCB track is focused on translational bioinformatics and personalized medicine. The ONC funding is limited to the CI and HIM tracks.

The certificate and degree programs are implemented on a building-block model, where courses at any level can be carried to programs at higher levels. The most basic program is the Graduate Certificate program, which is offered for the CI and HIM tracks. (The HIM Graduate Certificate is CAHIIM-accredited and allows graduates to sit for the examination for the RHIA credential.) OHSU offers two master's degree programs which differ only in the culminating project being a thesis (Master of Science) or a capstone or internship (MBI). The master's degree programs are offered for the CI and BCB tracks (although HIM Graduate Certificate graduates can easily move into the CI master's programs). OHSU's PhD program is offered for the CI and BCB tracks. All CI and HIM track programs up to and including the master's degree programs are available both on-campus and via distance learning. The BCB track and PhD program are only available on the OHSU campus.

The introductory course in the CI track (BMI 510 - Introduction to Biomedical and Health Informatics) was also adapted to be the original course in the AMIA 10x10 ("ten by ten") program, which aims to education 10,000 professionals in informatics by the year 2010. It has been the most subscribed course in the 10x10 program, and about 15% of graduates have gone on to further study in the OHSU Biomedical Informatics Graduate Program.

Why study biomedical informatics at OHSU? We have a long-standing program that is one of largest in active enrollment as well as alumni. Our 230+ alumni have taken a variety of jobs in healthcare organizations, academia, industry, government, and other settings. We also have a full-time faculty who are not only passionate about teaching but also accomplished researchers and thought leaders in the field. Finally, our program is a real graduate program and not a continuing education program.

Explaining the HITECH Workforce Development Program

2010-05-02T05:31:00.000-07:00

The word is slowly getting out on the Office of the National Coordinator for Health IT (ONC) HITECH Workforce Development Program. Naturally I am interested in the word getting out, since Oregon Health & Science University (OHSU) is playing a major role in the program.

One of the most enjoyable interchanges so far has been with Anthony Guerra, Editor of the healthSystemCIO.com site. It began when I took exception to a posting of his wondering whether the ONC workforce funding might be "fast and loose spending of taxpayer money." I expressed my disagreement, which led him to interview me for his site. He prefaced the interview with a posting explaining its context. The full interview, which includes about 20 minutes of audio, provided me the opportunity to defend the program, at least what we at OHSU plan to do with our funding (described in an earlier posting in this blog).

While the OHSU press release has been replicated all over the Internet (as all press releases are), a few publications have actually written their own stories. One is Healthcare IT News.

The American Medical Informatics Association (AMIA) is also working on a press release touting all of the HITECH funding that its members have received.

And of course, ONC has something to say itself about the workforce funding.

Not related to the workforce funding, I was also recently a HIMSS featured member in their HIMSS Insider e-newsletter.

The Dust Settles on HITECH Funding for Development of the Health Information Technology Workforce

2010-04-24T18:58:00.000-07:00

One of the elements deemed essential for "meaningful use" of health information technology (HIT) as legislated in the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA) was an adequately trained professional workforce. Section 3016 tasked the Office of the National Coordinator for Health IT (ONC) will developing programs to meet the needs for this workforce. Of the $2 billion allocated for HIT infrastructure in HITECH (to support the awarding of $36-40 billion in incentives for electronic health record adoption), a total of $118 million was allocated to four programs for workforce development.

The focus of this funding was on short-term training to develop professionals in 12 job roles (described in the Funding Opportunity Announcements and reproduced in an earlier posting in this blog). An analysis by ONC estimated a need for an additional 51,000 personnel above and beyond the existing HIT workforce. The bulk of these individuals fall into six of the job roles that will be trained in community colleges, while the remainder in the other six job roles will be trained in universities.

Three of the programs are focused on the community college training:

Community College Consortia to Educate Health Information Technology Professionals Program - This $70 million program establishes five regional consortia of 70 community colleges that will develop short-term certificate programs to train 10,000 individuals per year in the six community college job roles. Programs are expected to enroll their first students, most of whom will bring backgrounds in healthcare or information technology, by September 30, 2010.

Curriculum Development Centers Program - Because many of the community colleges in the new consortia do not have existing HIT educational programs, $10 million has been allocated to five universities with graduate-level educational programs to collaboratively develop (with community college partners) HIT curriculum for 20 components (topics). Members of the community college consortia will be able to use the components in whole (as courses) or in part. One of the five centers (Oregon Health & Science University) is additionally funded to serve as the National Training and Dissemination Center that will archive and distribute the curricula, train community college faculty in its use, and collect feedback to facilitate its improvement.

Competency Examination for Individuals Completing Non-Degree Training Program - Northern Virginia Community College has been provided a $6 million grant to develop and provide initial administration of a set of HIT competency examinations focused on the six community college job roles.

The fourth program is focused on university-based training:

Program of Assistance for University-Based Training - This $32 million training grant funds education of individuals in the six job roles requiring university-level training at nine universities (or consortia of universities). The funded programs will be able to use the funding as financial aid for students in their existing, mostly graduate-level, programs. The emphasis of the funding will be on short-term certificate programs delivered via distance learning, training about 500 individuals per year. While the focus of the program is on training individuals who will work in health care settings, some of the programs will also be training personnel to work in public health settings.

Taken together, these programs represent an unprecedented investment in HIT education and professional development. My hope is that not only will the individuals trained in these programs find rewarding careers in healthcare and public health organizations, regional extension centers, governments, and companies, but that biomedical/health informatics and related HIT disciplines will achieve more visibility as career options when the funding ends. Similar to information professionals in other industries, the need for these individuals will not go away when the HITECH funding ends.

ONC Grant Provides Financial Aid for Clinical Informatics Education

2010-04-10T13:05:00.000-07:00

My last posting noted that Oregon Health & Science University (OHSU) was awarded two grants totaling $5.8 million in American Recovery and Reinvestment Act (ARRA) funds to advance health information technology (HIT) education. In this entry, I will begin to describe the details, especially for those who might be eligible for this funding. This posting contains the initial text of what will be a continually updated page for those interested in the program.

One of the grants is for direct financial aid for students studying in HIT-related fields. In the case of OHSU, this funding will support the education of approximately 150 students over the next three years in OHSU's Biomedical Informatics Graduate Program. These funds will support tuition and fees for about 45 new students per year to enroll in and complete the university's online Graduate Certificate Program in Biomedical Informatics. The funding will also enable two cohorts of around students to enroll in OHSU's on-campus Master of Biomedical Informatics (MBI) Program, including a stipend and student health insurance. This funding is provided via a training grant from the Office of the National Coordinator for Health IT (ONC).

There are some restrictions on this funding beyond the usual program requirements:

Students must be U.S. citizens or permanent residents.
Students must not have been enrolled in the OHSU or any other informatics or health information technology educational program on or before December 17, 2009 (i.e., current students are not eligible). This restriction does not apply to students who have completed only the OHSU-AMIA 10x10 Program.
Students pursuing the Graduate Certificate Program must complete the program within one academic year.
Students pursuing the Master of Biomedical Informatics (MBI) Program must enroll as full-time on-campus students to receive the stipend and student health insurance.
Students must declare one of six job roles defined by ONC and follow a course of study commensurate with that role.

Students who are not eligible or who are interested in other areas of biomedical informatics (such as bioinformatics) should apply to the existing program.

Details of the admissions process are being finalized and applications will be available in mid-May for Fall 2010 admission. Please check this page frequently for more details. By mid-April, this page will include a sign-up form for students who wish to receive email updates on the status of the program.

ONC Program Details

OHSU's eight-course Graduate Certificate Program is entirely online and can be completed in two to four academic quarters. Students who are funded through this program will receive support for their tuition expenses and must complete its requirements within one year. (The Health Information Management Track of the Graduate Certificate Program requires additional courses which will be fully funded under this program.)

The Master of Biomedical Informatics (MBI) degree program requires about 1 1/2 years of full-time study. The funding provides MBI students with tuition support, a stipend and student health insurance.

Students receiving financial aid will be required to choose among six career paths defined by ONC:

Clinician/public health leader
Health information management and exchange specialist
Health information privacy and security specialist
Research and development scientist
Programmers and software engineer
Health IT sub-specialist

Students will be able to enroll in the new programs Fall 2010. More information about applying, degree requirements and financial aid will be available on this page in mid-May, 2010.

More About Our Program

OHSU offers a full range of graduate programs in biomedical informatics for cutting-edge and rewarding careers using information and associated technologies to advance individual health, healthcare, biomedical research, and public health. There are two main tracks in the program: clinical informatics and bioinformatics/computational biology. The clinical informatics track, with the exception of the PhD program, is available via distance learning. Other forms of financial aid, such as our National Library of Medicine Training Grant, are available for full-time on-campus PhD or postdoctoral master's students in both tracks.

OHSU Awarded $5.8 Million to Expand Health Information Technology Education

2010-04-07T23:30:00.000-07:00

The "holding pattern" (see last post) has ended, and most of the ARRA/HITECH funding has now been awarded. Last week, OHSU received word that two grants for curriculum development and student financial aid from ARRA Section 3016 Health IT Workforce Development will be funded. In the near future, I will share more information and thoughts about the workforce funding programs, their implications for informatics education and the profession, and some of the other ARRA/HITECH-funded programs. In the meantime, however, I share below the text of the press release from OHSU.

04/07/10 Portland, Ore.

Oregon Health & Science University has been awarded $5.8 million in American Recovery and Reinvestment Act (ARRA) funds to advance the widespread adoption and meaningful use of health information technology (HIT) by educating professionals to work in this rapidly growing field.

The funding is provided in two competitively awarded grants. One will directly support the education of about 150 additional students over three years in OHSU’s biomedical informatics graduate program while establishing additional capacity that will meet the ongoing needs of an expanded work force. The other award will establish a national dissemination resource for health IT curricula at OHSU.

The stimulus funds, awarded by the Office of the National Coordinator for Health Information Technology, will enable OHSU to help educate the estimated 50,000 professionals needed to convert the entire country to electronic health records by the year 2014. The recovery act authorizes an estimated $40 billion to achieve this goal.

“We are delighted to be able to contribute to the national initiative to educate the health IT professional work force that will be required to lead the widespread adoption of electronic health records,” says William Hersh, M.D., professor and chairman of OHSU’s Department of Medical Informatics and Clinical Epidemiology. “This work force is a key requirement for achieving ‘meaningful use’ of health information technology that will help to improve the quality and safety of health care while lowering its costs.”

Through this recovery act funding, OHSU will provide financial aid for nearly 140 new students to enroll in and complete the university’s online Graduate Certificate Program in Biomedical Informatics. The funding also will allow at least 12 students to enroll in and complete OHSU’s on-campus master's degree program. All financial aid under this grant is for students in graduate-level programs requiring a minimum of a bachelor’s degree for admission.

Students receiving financial aid will be required to choose among six career paths:
• Clinician/public health leader
• Health information management and exchange specialist
• Health information privacy and security specialist
• Research and development scientist
• Programmers and software engineer
• Health IT sub-specialist

The eight-course graduate certificate program is entirely online and and can be completed in two to three academic quarters. Students who are funded through this program will receive support for their tuition expenses and must complete its requirements within one year.

The master’s degree program requires about 1½ years of full-time study. The funding will not only provide these students with tuition support, but includes a stipend and student health insurance.

“Biomedical informatics is a growing field with opportunities for people with a variety of backgrounds, especially in health care, computer science and information technology,” added Hersh. “Although this funding is focused on training professionals to implement electronic health records, there are numerous other career opportunities in such areas as personal health records, telemedicine, clinical and translational research, and bioinformatics.”

The National Training and Dissemination Center will support a total of five Curriculum Development Centers, one of which will be housed at OHSU. Together, the five centers will develop curricula for the five community college consortia being established to train community college students in HIT. These curricula will also be made available to institutions of higher education throughout the nation. The National Training and Dissemination Center will house the curricula on a dedicated Web site, train community college faculty in its use, and collect and disseminate feedback on its content.

The Curriculum Development Center at OHSU is a partnership between OHSU and four local community colleges — Portland Community College, Mt. Hood Community College, Lane Community College and Umpqua Community College.OHSU and community college faculty will collaborate to tailor the curricula for community college students.

OHSU is an established national leader in health information technology education. Its existing educational programs are among the largest in the country, and it has led many innovations, such as the 10x10 (“ten by ten”) program in partnership with the American Medical Informatics Association, which aims to train 10,000 health care professionals in biomedical informatics by the year 2010.

Students will be able to enroll in the new programs this fall. More information about student financial aid opportunities will be available on the OHSU Department of Medical Informatics and Clinical Epidemiology Web site in early May. In the meantime, for descriptions of the Graduate Certificate and Master’s degree programs or to sign up to receive further information when it becomes available visit: http://www.ohsu.edu/dmice.

The Health IT Holding Pattern (or Calm Before the Storm?)

2010-03-17T07:48:00.000-07:00

Despite all the frenzy over HITECH, a large part of the health IT community seems to be in a holding pattern. Maybe it is the calm before the storm. Hospitals and physician practices are waiting for the final criteria for meaningful use now that the comment period has ended. (More on those in a moment.) Researchers and innovators are waiting to hear respectively about their SHARP and Beacon proposals, while educators are waiting to hear about their workforce development proposals.

For those interested in workforce-related issues, such as certification, the press has not been quiet. A recent article by Joseph Conn described where things with a focus on physician certification, while another article by Bruce Bollag describes the ONC workforce funding initiatives in more detail.

In the meantime, a number of groups have put forth thoughtful critiques of the interim rules for meaningful use. The entirety of comments can be seen at Regulations.gov. It will be interesting to see how ONC and CMS take these into account and what modifications they make. Here are some published letters from some of the more prominent organizations:

A group of 96 physician associations
American Medical Informatics Association (AMIA) comments on the CMS NPRM and ONC IFR
American Health Information Management Association (AHIMA)
Association of American Medical Colleges (AAMC) comments on the CMS NPRM and ONC IFR
Consumer Partnership for eHealth
eHealth Initiative
American Hospital Association
American Academy of Family Physicians
Premier (insurance group purchaser)
Medical Group Management Association
HIMSS EHR (Vendor) Association comments on the CMS NPRM and ONC IFR
Combined comments from the Markle Foundation, the Center for American Progress, and the Engelberg Center for Healthcare Reform of the Brookings Institute on the CMS NPRM and the ONC IFR

Fortunately the wheels of educational opportunity are not standing still. AMIA has announced three offerings of the OHSU 10x10 course. Two are oriented to specific professional groups, while the other is oriented to the usual general clinical informatics audience. More information for each can be found at the following links:

General clinical informatics
Emergency medicine physicians (in partnership with the American College of Emergency Physicians)
Dietitians (in partnership with the American Dietetic Association)

Informatics Professor Postings Motivate Articles and Talks

2010-02-27T17:11:00.001-08:00

Some items of interest motivated by prior postings from the Informatics Professor blog!

First, OHSU published one of its ongoing advertisements in the Opinion section of a recent Sunday Oregonian about healthcare reform that featured my views on how biomedical informatics will enable information use to improve healthcare quality, safety, and cost (as described in a prior blog posting). The views are consistent with OHSU's eight principles for healthcare reform, one of which is, "Supports more effective deployment of information technology, including but not limited to portable electronic health care records."

Second, the university published a piece that described my trip and Health Affairs article that motivated my prior post on "global truths."

Finally, I was recently invited to give a talk at the University of Michigan, where I gave a talk motivated by another recent post about informatics now living in a HITECH world. There are links to a video of my talk as well as my slides with references.

Informatics is a Field of Global Truths

2010-02-13T06:20:00.000-08:00

As all of my friends on Facebook know, I recently spent an enjoyable two weeks in Asia, with stops in Hong Kong, Singapore, and Bangkok. Certainly one of the things I enjoy most about my work is getting to interact with colleagues in the field from all over the world.

One thing I have definitely learned in my countless interactions with friends, colleagues, and others in Europe, South America, Asia, Africa, and elsewhere is that the principles of informatics apply no matter where you are on the planet. There are indeed global truths in the informatics field, just as there are in medicine, i.e., while different diseases occur with different frequencies and somewhat different manifestations around the globe, the same basic pathologies that afflict the human organism do so no matter where the human is located. Whether it is infectious diseases or chronic diseases, relatively similar approaches to diagnosing and treating disease apply universally.

I believe that the same notion applies in informatics. That is, the factors that motivate and govern informatics in the United States do the same elsewhere, i.e., the use of information to improve human health, healthcare, public health, and biomedical research. This does not mean that some of the issues manifest themselves in diverse ways in different settings. But principles like the need to understand the clinical setting and its workflows as well as to provide value to the full spectrum of "users" from clinicians and citizens to institutional leaders and ministries of health apply universally.

I have also come to learn in this journey that there is a global need to build human capacity in informatics. Indeed, I had the opportunity to share thoughts and a framework for developing it in a paper published in the current issue of the journal Health Affairs, which is devoted to eHealth in the developing world. My co-authors include Dr. Alvaro Margolis from Uruguay and Drs. Fernan Quiros and Paula Otero from Argentina. Other papers in the issue focus on other issues and challenges in this area, such as standards and interoperability, use of mobile health (mHealth) technologies, and policy development. As most people who work in this area know, there has been an explosion in the growth of mobile phone technology and its use to truly benefit these developing economies. A press release from the American Medical Informatics Association also summarizes the papers.

On February 16th, I will be in Washington, DC participating in a press event about the papers in this issue of Health Affairs. I intend to make the above points in the few minutes that I have to talk.

The notion of global truths in informatics was clearly visible on my recent trip. My first stop was in Hong Kong to lead a two-day seminar on health informatics for allied health professionals in the Hong Kong Hospital Authority. The Hospital Authority is undertaking an impressive comprehensive national program to develop a universal electronic health record (EHR) for all public hospitals. This system will also facilitate health information exchange (HIE) from private hospitals. One of the main reasons for the project's success to date has been the leadership of Dr. NT Cheung, who has paid meticulous attention to both the needs of all stakeholders of the system as well as the most appropriate technologies to be implemented. He has also assembled a well-trained team (some of whom I have also trained in the 10x10 course!). We (including those of us in the United States) can learn plenty about the right way to do informatics in this effort.

My next stop was Singapore, where I have been running an offering of the 10x10 course with my colleague Dr. KC Lun of Gateway Consulting. Although the course has attracted a regional audience, a large number of participants have come from the Singapore Ministry of Health Holdings and local healthcare institutions. There are many robust informatics projects being undertaken in Singapore, including a national EHR with HIE from various hospitals.

My final stop on the trip was Bangkok, Thailand, a country with a rich tradition of a strong healthcare system. One event in Bangkok was the opportunity to give a talk about informatics to the Dean and the clinical department chairs of the Ramathibodi Hospital Faculty of Medicine of Mahidol University. Being a department chair in a medical school myself, I had a natural kinship with this group, and enjoyed in engaging them in a well-informed conversation.

I also attended in Bangkok the Prince Mahidol Award Conference, which is an annual conference devoted to global health issues. The theme of this year's conference was Global Health Information Systems and how they can improve individual health, better inform health leaders, and improve the delivery of healthcare and public health. I gave a presentation on a panel devoted to the human resources capacity required to achieve optimal use of such information systems. The conference also adopted a Call to Action that, among other things, called for investments in building capacity.

I look forward to my continued work with colleagues around the world to build the capacity that allows informatics to play its role in improving health, healthcare, public health, and biomedical research.

Some interesting recent articles

2010-02-08T15:02:00.000-08:00

With the increasing visibility of informatics careers, due in large part to ARRA/HITECH funding, comes increasing attention from the press about opportunities for training. Here are three recent interesting articles:

An overview of the 10x10 program in a health care workforce publication.
An article on career opportunities in clinical informatics, including an opportunity to meet some clinical informaticians.
An article on informatics opportunities in clinical and translational research. (Important point about this article: although clinical informatics is getting most of the press these days, it is important to remember there are other areas of the field that also provide opportunity, including informatics applied to clinical and translational research.)

Informatics Now Lives in a HITECH World

2010-01-24T00:18:00.000-08:00

The flurry of activity from the Office of the National Coordinator for Health IT (ONC) in late 2009 laid out the implementation plans of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the economic stimulus package). The scope of programs was so immense that few aspects of the biomedical and health informatics field will be unaffected by HITECH. I think we can plainly say that informatics now lives in a HITECH world.

The discipline of biomedical and health informatics has had an increasingly important and visible role in individual health, healthcare, public health, and biomedical research in recent years. But HITECH will impact virtually every aspect of our field. It will certainly define the path and set the implementation priorities for hospitals and physician offices implementing their electronic health records (EHR). HITECH will drive the standards agenda for health data and information. It will also set the bar for privacy and security matters. Finally, HITECH will drive the academic informatics agenda through its impact on research programs (the SHARP program), demonstration projects (the Beacon program), and education (the health IT workforce funding initiatives).

There will, of course, be some activity outside the confines of HITECH. More fundamental research and training of future researchers will continue to be the purview of the National Library of Medicine (NLM). Informatics will continue to play a key role in the Clinical and Translational Science Award (CTSA) program of the National Institutes of Health (NIH). Likewise, the Agency for Healthcare Research and Quality (AHRQ) will likely continue its quality and comparative effectiveness research agendas with the heavy utilization of health IT. But even all of these programs will be impacted by HITECH's provisions and regulations concerning EHR data, its driving of the research agenda, and its influence on curricula in educational programs.

There has been much written in detail about various aspects of HITECH. Probably the best big picture overview is the New England Journal of Medicine article by the National Coordinator himself, Dr. David Blumenthal. This paper lays out the vision of "meaningful use" of health information and the ONC's planned path for achieving it. There are also a number of Web sites and blogs that maintaining ongoing information and commentary about the programs. These include:

Geek Doctor blog - I have to commend Dr. Halamka for keeping us up to date with a very readable overviews of the emerging programs, regulations, technologies, etc.
HIMSS - Also has a nice site, some of which is limited to members only, that also is kept up to date well
AHIMA - Also starting to provide materials on meaningful use and related topics as well
HISTalk - this more eclectic blog provides other interesting perspectives

There are many other interesting and informative sites, and I am not meaning to slight any of those by not including them. But the above sites are good entry points for those wishing to learn more about how HITECH will drive the EHR implementation agenda in the coming years. Google and other search engines can also be very helpful for finding more information, as can professional organizations to which readers may belong and that provide their perspectives. A nice consultant-style overview is provided by David Classen and Erica Drazen of CSC Corp..

It is important to remember that the goals of HITECH are ultimately rooted in improving individual health, healthcare, and public health. The goal is not adoption for the sake of technology. All HITECH rules, regulations, incentives, programs, etc. are linked to one of five underlying goals for the healthcare system:

Improving quality, safety and efficiency
Engaging patients in their care
Increasing coordination of care
Improving the health status of the population
Ensuring privacy and security

The financial incentives for EHR adoption are enshrined in two key documents that were released in late December, 2009. Both of these documents are interim documents, with 60-day comment periods before being finalized in the spring. These documents are:

The Notice of Proposed Rule-Making (NPRM) - the rules for how incentives for meaningful use will be funded through Medicare and Medicaid reimbursement by the Centers for Medicare and Medicaid Services (CMS)
The Interim Final Rule (IFR) standardizing what will be required to achieve meaningful use of EHRs by ONC

The NPRM defines eligible professionals and hospitals who can qualify for the meaningful use incentives. It stipulates what these professionals and hospitals must do over what time frame to achieve the incentive payments. Meaningful use is defined to consist of three requirements:

Use of certified EHR technology in a meaningful manner
Utilize certified EHR technology connected in a manner that provides for the electronic exchange of health information to improve the quality of care
Using certified EHR technology, the provider submits information on clinical quality measures

The NPRM defines three phases of increasing criteria and dates by which they must be accomplished to receive incentive payments. These phases were formerly named by the year that providers needed to implement them - 2011, 2013, and 2015 - but are now called stages, with the maximum incentive dollars received by those who implement them by those dates (i.e., stage 1 in 2011, stage 2 in 2013, and stage 3 in 2015). Eligible professionals and hospitals who implement them at later dates receive less funding, and all who do not implement stage 3 by 2015 are assessed a penalty through decreased Medicare or Medicare reimbursement.

The stages of adoption and their key features are as follows:

Stage 1 - electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, implementing some clinical decision support tools, and initiating the reporting of clinical quality measures and public health information.
Stage 2 - expand on Stage 1 to focus on continuous quality improvement at the point of care and the exchange of information in the most structured format possible.
Stage 3 - focus on promoting improvements in quality, safety and efficiency by encouraging decision support, patient access to self-management tools, access to comprehensive patient data, and improving population health.

The NPRM presents the requirements for Stage 1 use of an EHR by hospitals and professionals in a meaningful manner. There are 23 criteria, which differ slightly whether for hospitals or professionals (pp. 103-108). Each is tied back to one of the five healthcare outcomes goals listed above. Some of the better known and more widely discussed criteria include:

Use computerized provider order entry (CPOE) for orders (any type) directly entered by authorizing provider. One of the differences between hospitals and professionals is that the former are required to use CPOE for 10% of all orders whereas professionals are required to use it for 80%.
Implement drug-drug, drug-allergy, and drug-formulary checks.
Maintain an up-to-date problem list using ICD-9 or SNOMED.
(Professionals only) Use electronic prescribing for 75% of all prescriptions.
Exchange key information electronically among providers of care and other patient-authorized entities.
Provide summary care record for 80% of care transitions.
Provide electronic syndromic surveillance data electronically to public health agencies.
(Professionals only) Provide patients with electronic access to their information for 10% of all patients.
Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities.

Some of these criteria are open to interpretation and it is likely some will be modified when the final rule is issued. Many organizations have taken issue with various aspects of these criteria, usually arguing that the definitions are vague and/or they are not likely to be achieved, even for organizations that already have advanced EHR implementations.

The NPRM also lists the quality measures that meaningful users must report on in Stage 1. There are listed 35 clinical quality measures in nine categories for which hospitals must report to meet the meaningful use criteria (pp. 152-162). All of the measures have been endorsed by the National Quality Forum, and 25 have been adopted by the Hospital Quality Alliance. However, only nine of the measures are currently in use in Medicare's pay-for-reporting program, meaning that hospitals may face significant challenges in implementing the new measures if they are all adopted in the final rule. Hospitals will be required to report on all quality measures for which they have any applicable patients, not just for measures applicable to their Medicare patients.

For eligible professionals, the NPRM has a list of 90 quality measures that are grouped into 15 categories by specific medical specialties (pp. 143-151). Professionals must only report on measures for the category of professional in which they fall.

The IFR provides a definition of certified EHRs and an initial set of standards, implementation specifications, and certification criteria for EHRs. It creates standards for certified EHRs in four categories: content, vocabulary, transmission, and privacy/security. Certified EHR Technology is defined by the IFR as consisting of a Qualified EHR that has been certified by an authority designated by the Department of Health & Human Services (in a process to be determined). A Qualified EHR consists of an electronic record of health-related information on an individual that:

Includes patient demographic and clinical health information, such as medical history and problem lists.
Has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to health care quality; and exchange electronic health information with, and integrate such information from other sources.

Of course, as Dr. Blumenthal notes in his New England Journal of Medicine article, achieving the goals of HITECH and meaningful use will not happen with the financial incentives alone. There needs to be an infrastructure that will support the path to getting there. He notes a number of programs that are also funded under HITECH that will help hospitals and professionals reach meaningful use, especially primary care physicians in under-resourced practices. About $2 billion of ARRA funding has been devoted to these programs.

One substantial supporting program will be the Health IT Regional Extension Centers (RECs). About 70 RECs will be funded with $643 million to provide guidance, mainly to small primary care practices, in achieving meaningful use. Because there will be 70 programs, some larger states will have more than one REC while some smaller states will participate in multi-state RECs. These programs will have some similarity to the long-standing agricultural extension service that farmers have relied on for years to improve the capabilities of their farms.

Another key component to achieving meaningful use, likely familiar to readers of this blog, is development of the health IT workforce. The details of these programs have been described in previous postings, but essentially two types of programs will be funded. One will be the funding of five regional community college consortia to achieve 51,000 trained workers over five years (10,500 per year, starting in the fall of 2010) in six specific job roles. The other program will be the funding of universities to train another 1000-1500 individuals per year over three years for six additional higher-level job roles. Also funded under this initiative will be Curriculum Development Centers, mainly to assist community colleges, and a certification examination for graduates of the community college programs. A total of $118 million will be funded under these programs.

Additional funding will go for the following programs (and some additional ones in Dr. Blumenthal's paper and not listed here):

State-based health information exchange (HIE) - $564 million in grants to the states to develop HIE programs.
Beacon communities - $235 million to fund up to 15 communities that provide exemplary demonstration of the meaningful use of EHRs to bring out measurable improvement in the quality and/or efficiency of healthcare and/or public health.
Strategic health information advanced research projects (SHARP) - $60 million for four collaborative research centers in the areas of: Security for Health Information Technology, Patient-Centered Cognitive Support, Healthcare Application and Network Platforms, and Secondary Use of EHR Data

I think it is safe to say that ONC and the rest of the government have "played their cards" in the implementation of HITECH, and the above rules and programs will drive the agenda of biomedical and health informatics and related health IT for years to come. These efforts now define what the key functions of EHR systems will be, how hospitals and professionals will fund their use, and what quality measures hospitals and professionals will need to report. The agenda for HIE will now be more clearly defined and very focused at the level of individual states. These programs also define the pathways for various professionals to enter the workforce and provide funding for them. Finally, leadership for both demonstration projects as well as the research agenda will be funded through the Beacon and SHARP programs.

Some ONC leaders have stated that HITECH is a "down payment" on health care reform. Of course, given the state of the health care reform debate as I write this in mid-January, I am not sure what the final payment will be or what healthcare will be in place as these programs are implemented. I do hold the opinion that HITECH is more likely to succeed if we transform our healthcare system to one that better values quality and efficiency, but even under the present system, it is likely to result in some positive improvement.

This is a defining moment for the informatics field. Never before has such money and attention been lavished on it. HITECH provides a clear challenge for the field to "get it right." It will be interesting to look back on this time in the years ahead and see what worked and did not work. Whatever does happen, it is clear that informatics lives in a HITECH world now.