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

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

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)
  

The Genesis of the 10x10 Course

The 10x10 ("ten by ten") program was launched in 2005 by the American Medical Informatics Association (AMIA) and Oregon Health & Science University (OHSU). The genesis for the program came when then-President of AMIA, Dr. Charles Safran, called for at least one physician and one nurse in each of the 6000 hospitals in the US to have some training in medical informatics. At the same time, AMIA was looking to develop e-learning materials for training in medical informatics, but found that vendors were proposing unaffordable fees.

At that time, the biomedical informatics distance learning program at OHSU was mature and included an introductory course that I had been teaching on-line for nearly a decade. I proposed to AMIA that we re-package this course into a standalone course that included an in-person session at the end (not present in the OHSU course) that brought participants together for interaction and additional learning. Based on Dr. Safran's numbers and my knowledge of the scalable capacity of the distance learning course, I proposed that we name the program 10x10, embodying the aim of training 10,000 individuals in medical informatics by the year 2010.

The training would of course not be limited to physicians and nurses, nor would it be limited to US citizens. AMIA and OHSU negotiated a mutual non-exclusivity agreement, in which AMIA could accredit other educational institutions to offer 10x10 courses and OHSU would continue to own its intellectual property and use it for other initiatives besides 10x10.

The first cohort of 44 students completed the course in 2005. In addition to the "standard" offering of the course being offered to coincide with the in-person session at the end coinciding with an AMIA spring or fall meeting, a number of special offerings have been developed, tailored to specific audiences. These include:

• California Health Care Foundation (2006) - California physicians
• American College of Physicians (2007) - internal medicine physicians
• Scottsdale Institute (2007) - an organization of innovative health care systems
• Mayo Clinic (2007 and 2008) - senior nursing executives, embedded in a larger program centered around health care quality
• Society for Technology in Anesthesiology (2008) - anesthesiologists
• American College of Emergency Physicians (2008) - emergency medicine physicians

In addition, AMIA received a grant from the Centers for Disease Control and Prevention (CDC) in 2008 to organize education for public health professionals in public health informatics in 2008. Part of the grant went to providing the tuition for some of those professionals to enroll in several 10x10 offerings, including OHSU's.

By the end of 2008, a total of 582 people had completed the OHSU offering of the AMIA 10x10 course. While far short of the goal of 10,000, the capacity of course could handle many more people.

Students in 10x10 have come not only from the US, but also from many other countries, including Canada, Argentina, Hong Kong, Kuwait, Pakistan, Israel, and Thailand. One of the original students from Argentina, Dr. Paula Otero, translated the course into Spanish and has delivered it to 380 individuals across Latin America.

The course has also inspired federal legislation in the US, leading to the "10,000 Trained by 2010 Act," introduced by Rep. David Wu (D-OR). The bill was passed by the US House in the 110th Congress (2007-2008) but did not have a Senate sponsor. It has been introduced in the 111th Congress, and elements of it have been incorporated into the American Recovery and Reinvestment Act of 2009, aka, the economic stimulus package.

A demo version of the introductory graduate course from which 10x10 is derived can be accessed at the URL:
http://sakai.ohsu.edu/xsl-portal/site/b6042e92-ea91-442a-af63-d3f882d2e88c
From this page, log in with the following:
Username: bmi_demo
Password: format

More information about 10x10 can be found on the AMIA web site at:
http://www.amia.org/10x10/
Information about the most current OHSU offering is at:
http://www.amia.org/10x10/partners/ohsu/

A number of papers have been written about the 10x10 program:
Hersh, W. and Williamson, J. (2007). Educating 10,000 informaticians by 2010: the AMIA 10×10 program. International Journal of Medical Informatics, 76: 377-382.
Feldman, S. and Hersh, W. (2008). Evaluating the AMIA-OHSU 10x10 program to train healthcare professionals in medical informatics. AMIA Annual Symposium Proceedings, Washington, DC. American Medical Informatics Association. 182-186.
Otero, P., Hersh, W., et al. (2007). Translation, implementation and evaluation of a medical informatics distance learning course for Latin America. MEDINFO 2007 - Proceedings of the Twelfth World Congress on Health (Medical) Informatics, Brisbane, Australia. IOS Press. CD-ROM P421.
Hersh, W. (2007). The full spectrum of biomedical informatics education at Oregon Health & Science University. Methods of Information in Medicine, 46: 80-83.