Thursday, December 31, 2009

A New Year's Moment to Reflect

The year 2010 will mark my 20th year at Oregon Health & Science University (OHSU). I arrived at OHSU in 1990 as a newly minted Assistant Professor, fresh out of a three-year medical informatics fellowship in Boston that followed my medical training (medical school and internal medicine residency in Chicago). I have seen a great deal of change in our field since my tenure in it began, but I don't believe there has been anything quite like this past year, 2009.

I remember quite vividly as 2009 began. While I was excited at the election of our new president and his fresh hope for change, I was more than a little concerned about the onset of the economic recession and its impact on the finances of OHSU. Based on what we were hearing, I was having some serious doubts about the viability of OHSU and our Department of Medical Informatics & Clinical Epidemiology, as cuts to the small but essential amount of support (about 5% of our overall budget) we received from the university looked threatened. Furthermore, the potentially draconian cuts in other departments greatly threatened institutional morale.

Within a month or two of the new year, however, a different picture began to emerge. Something called the American Recovery and Reinvestment Act (ARRA, also known as the economic stimulus package) had just come to be, and within it, something called the Health Information Technology for Economic and Clinical Health (HITECH) Act promised unprecedented new support for health information technology (HIT). I even played a small role in the development of ARRA, contributing a few words that made it into what became Section 3016, the portion legislating support for health IT workforce development, working with the staffs of my Congressman David Wu and one of my state's Senators, Ron Wyden. (ARRA has also greatly benefited some, but not all, of the other departments at OHSU.)

In addition to new acronyms that are now household names (at least for those of us in informatics), such as ARRA and HITECH, new phrases appeared in the vernacular, mostly notably "meaningful use." As an educator and frequent speaker on the topic, the constant unveiling of new details made it a challenge to keep all my slides up to date.

The year of unprecedented activity came to a head in the last month of 2009. The trickle of funding opportunity announcements (FOAs)turned into a torrent, with the Office of the National Coordinator for Health IT (ONC) laying out its implementation of the vision of HITECH. The tight mid to late January deadlines for these FOAs released in December led a colleague to quip that ONC stood for the "Office of No Christmas" (to which I added, "Office of No Chanukah" for those of a different religious persuasion). Like many, I have spent a good deal of this year's Christmas break working on proposals for the FOAs.

On the second to the last day of the month and year, ONC, along with the Centers for Medicare and Medicaid Services (CMS), released the Notice of Proposed Rulemaking (NPRM) for the "meaningful use" criteria that will guide the distribution of financial incentives for EHR adoption under HITECH. Further released was the interim final rule (IFR) on Standards & Certification Criteria, the initial set of standards, implementation specifications, and certification criteria for the interoperability, functionality, utility, and security of health IT. A good starting point for digesting all the information associated with these is the ONC news release and overview. From these, you can link to a fact sheet on the IFR.

Readable and succinct summaries are also available from CMS about the program in general, the meaningful use standards, the meaning of certified electronic health records, and the requirements for incentive funding in the Medicare and Medicaid programs. No doubt a number of summaries will appear in the coming days; two good ones to start come from the venerable blogs HisTalk and Geek Doctor.

Also released on that day was an article in the New England Journal of Medicine by the National Coordinator of ONC, Dr. David Blumenthal, that gives a succinct, big-picture overview of HITECH. Dr. Blumenthal's article makes clear that if 2009 was the planning year, then 2010 will be the implementation year. We will see the finalization of the meaningful use criteria, the launching of the regional extension centers, the start-up of a number of other programs, and the initiation of the education and training programs to ramp up the necessary workforce to make it all happen.

Another event of 2010 will be the finalization of healthcare reform legislation. I have avoided expressing my views on healthcare reform this blog (considered out of scope!), but I agree with those who say there was more "reform" and transformation of healthcare in ARRA (courtesy of HITECH) than anything that will emerge out of the legislation due to be reconciled by the House and Senate in early 2010. I do agree, however, with those who see the imperfect legislation that will emerge from that process as a "foot in the door" to more meaningful healthcare reform in the years ahead. It will not be a smooth or painless process.

So ONC has now put its proverbial cards on the table, and it is very clear how they plan to implement HITECH. There probably is not a single person in the field who agrees with everything they are doing, but it is very clear that the health IT agenda in the US will be driven by the ONC agenda. A huge natural experiment is about to take place, and I for one am excited to be a "subject" in it!

Happy New Year to all.

Thursday, December 24, 2009

HIT Workforce: The ONC View

For those of us who are students of health information technology (HIT) workforce issues, the new funding opportunity announcements (FOAs) from the Office of the National Coordinator for Health Information Technology (ONC) provide an interesting glimpse into their view of the HIT workforce needed to meet the electronic health record (EHR) adoption goals of the American Recovery and Reinvestment Act (ARRA) of 2009. ONC Coordinator Dr. David Blumenthal gives a high-level vision of their approach in his blog.

In the FOAs, ONC lays out the job roles and competencies for the workforce that they believe is necessary to achieve meaningful use of EHRs. The information is spread out over the different FOAs, but I have attempted to bring it into a single narrative, which follows in this posting. The content for this posting was largely created by copy and paste from the ONC documents but I assume full responsibility for any errors introduced in my process. This is the workforce that ONC hopes to see trained with its $118 million investment in the four FOAs.

The roles are grouped into three general categories. Those with an asterisk (*) are slated to have training take place in community colleges, while those with a dagger (†) will have training occur in university-based settings. I will first list the categories and roles, and then provide more details on the roles and their competencies. (Again, to be clear, I am cutting and pasting from ONC documents, so this is not my work, but I do assume responsibility for any errors that I introduce.)

Category 1: Mobile Adoption Support Roles
These members of the workforce will support implementation at specific locations, for a period of time, and when their work is done, will move on to new locations. They might be employed by regional extension centers, vendors, or state/city public health agencies.
  • Implementation support specialist*
  • Practice workflow and information management redesign specialist*
  • Clinician consultant*
  • Implementation manager*
Category 2: Permanent Staff of Health Care Delivery and Public Health Sites

These roles are needed for ongoing support of health IT at office practices, hospitals, health centers, Long Term Care (LTC) facilities, health information exchange organizations and state and local public health agencies.
  • Technical/software support staff*
  • Trainer*
  • Clinician/public health leader†
  • Health information management and exchange specialist†
  • Health information privacy and security specialist†
Category 3: Health Care and Public Health Informaticians

These individuals will be based in universities, research centers, government agencies, and research and development divisions of software companies.
  • Research and development scientist†
  • Programmers and software engineer†
  • Health IT sub-specialist†
Now, here are the roles and their competencies in more detail.

Mobile Adoption Support Positions

These members of the workforce will support implementation at specific locations for a period of time, and when their work is done, will move on to new locations. Workers in these roles might be employed by regional extension centers, providers, vendors, or state/city public health agencies, and would work together in teams. Preparation for this set of roles will typically require six months of intense training for individuals with appropriate backgrounds

1. Practice workflow and information management redesign specialists
Workers in this role assist in reorganizing the work of a provider to take full advantage of the features of health IT in pursuit of meaningful use of health IT to improve health and care. Individuals in this role may have backgrounds in health care (for example, as a practice administrator) or in information technology, but are not licensed clinical professionals. Workers in this role will:
  • Conduct user requirements analysis to facilitate workflow design
  • Integrate information technology functions into workflow
  • Document health information exchange needs
  • Design processes and information flows that accommodate quality improvement and reporting
  • Work with provider personnel to implement revised workflows
  • Evaluate process workflows to validate or improve practice’s systems
2. Clinician/practitioner consultants
This role is similar to the “redesign specialist” role listed above but brings to bear the background and experience of a licensed clinical and professional or public health professional. In addition to the activities noted above, workers in this role will:
  • Suggest solutions for health IT implementation problems in clinical and public health settings
  • Address workflow and data collection issues from a clinical perspective, including quality measurement and improvement
  • Assist in selection of vendors and software
  • Advocate for users’ needs, acting as a liaison between users, IT staff, and vendors
3. Implementation support specialists
Workers in this role provide on-site user support for the period of time before and during implementation of health IT systems in clinical and public health settings. The previous background of workers in this role includes information technology or information management. Workers in this role will:
  • Execute implementation project plans, by installing hardware (as needed) and configuring software to meet practice needs
  • Incorporate usability principles into design and implementation
  • Test the software against performance specifications
  • Interact with the vendors as needed to rectify problems that occur during the deployment process
4. Implementation managers
Workers in this role provide on-site management of mobile adoption support teams for the period of time before and during implementation of health IT systems in clinical and public health settings. Workers in this role will, prior to training, have experience in health and/or IT environments as well as administrative and managerial experience. Workers in this role will:
  • Apply project management and change management principles to create implementation project plans to achieve the project goals
  • Interact with office/hospital personnel to ensure open communication with the support team
  • Lead implementation teams consisting of workers in the roles described above
  • Manage vendor relations, providing feedback to health IT vendors for product improvement
Permanent Staff of Health Care Delivery and Public Health Sites

These roles are needed for ongoing support of health IT that has been deployed in office practices, hospitals, health centers, long-term care facilities, health information exchange organizations and state and local public health agencies. Preparation for this set of roles will typically require six months of intense training for individuals with appropriate backgrounds.

5. Technical/software support staff
Workers in this role maintain systems in clinical and public health settings, including patching and upgrading of software. The previous background of workers in this role includes information technology or information management. Workers in this role will:
  • Interact with end users to diagnose IT problems and implement solutions
  • Document IT problems and evaluate the effectiveness of problem resolution
  • Support systems security and standards
6. Trainers
Workers in this role design and deliver training programs, using adult learning principles, to employees in clinical and public health settings. The previous background of workers in this role includes experience as a health professional or health information management specialist. Experience as a trainer in from the classroom is also desired. Workers in this role will:
  • Be able to use a range of health IT applications, preferably at an expert level
  • Communicate both health and IT concepts as appropriate
  • Assess training needs and competencies of learners
  • Design lesson plans, structuring active learning experiences for users
  • Track training records of the users and develop learning plans for further instruction
7. Clinician/Public Health Leader
By combining formal clinical or public health training with training in health IT, individuals in this role will be able to lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States. In the health care provider settings, this role may be currently expressed through job titles such as Chief Medical Information Officer (CMIO), Chief Nursing Informatics Officer (CNIO). In public health agencies, this role may be currently expressed through job titles such as Chief Information or Chief Informatics Officer. Training appropriate to this role will require at least one year of study leading to a university-issued certificate or master’s degree in health informatics or health IT, as a complement to the individual’s prior clinical or public health academic training.

8. Health Information Management and Exchange Specialist
Individuals in these roles support the collection, management, retrieval, exchange, and/or analysis of information in electronic form, in health care and public health organizations. We anticipate that graduates of this training would typically not enter directly into leadership or management roles.

9. Health Information Privacy and Security Specialist
Maintaining trust by ensuring the privacy and security of health information is an essential component of any successful health IT deployment. Individuals in this role would be qualified to serve as institutional/organizational information privacy or security officers.

Health Care and Public Health Informaticians

These individuals will be based in universities, research centers, government agencies, and research and development divisions of software companies.

10. Research and Development Scientist
These individuals will support efforts to create innovative models and solutions that advance the capabilities of health IT, and conduct studies on the effectiveness of health IT and its effect on health care quality. Individuals trained for these positions would also be expected to take positions as teachers in institutions of higher education including community colleges, building health IT training capacity across the nation.

11. Programmers and Software Engineer
We anticipate that these individuals will be the architects and developers of advanced health IT solutions. These individuals will be cross-trained in IT and health domains, thereby possessing a high level of familiarity with health domains to complement their technical skills in computer and information science. As such, the solutions they develop would be expected to reflect a sophisticated understanding of the problems being addressed and the special problems created by the culture, organizational context, and workflow of health care.

12. Health IT Sub-specialist
The ultimate success of health IT will require, as part of the workforce, a relatively small number of individuals whose training combines health care or public health generalist knowledge, knowledge of IT, and deep knowledge drawn from disciplines that inform health IT policy or technology. Such disciplines include ethics, economics, business, policy and planning, cognitive psychology, and industrial/systems engineering. The deep understanding of an external discipline, as it applies to health IT, will enable these individuals to complement the work of the research and development scientists described above. These individuals would be expected to find employment in research and development settings, and could serve important roles as teachers.

Sunday, December 20, 2009

Section 3016: More!

The Office of the National Coordinator for Health Information Technology (ONC) has released two more funding opportunity announcements (FOAs) for HIT workforce development. These are in addition to two previous FOAs that aim to establish community college consortia and the curricula they will utilize for rapid, short-term training of the workforce.

The first new FOA (OC-HIT-10-002) is entitled, Competency Examination for Individuals Completing Non-Degree Training. This FOA continues the emphasis on community colleges, consisting of a cooperative agreement for the development of competency testing for six job roles for which short-term community college programs are being developed. A single $6 million award will be given to an institution of higher education to perform this task. The awardee will be tasked with creating a detailed “blueprint” for implementation of the program, based on the competencies for the six workforce roles and providing structure for the content of the examinations. The awardee will be expected to collaborate with community colleges and competency-based subject matter experts to provide examinations that are suitable for the community college student population and other examinees. The awardee must also work with industry and employer groups to ensure that the materials are responsive to emerging workforce needs. They will be required to administer the exams through computer-based testing centers and the cost of the award must include their free administration to the 10,000 individuals who will be trained by the community college consortia.

The second new FOA (OC-HIT-10-003) is entitled, Information Technology Professionals in Health Care: Program of Assistance for University-Based Training. The goal of this to create training grants for university-based programs to train higher-level professionals to be part of the workforce that achieves the meaningful use of HIT. This FOA addresses a concern of many that all training was going to be carried out by community colleges. However, this FOA makes it clear that there is a role for many others, including at the leadership level, to move us toward the meaningful use of electronic health records (EHRs). A total of $32 million will be allocated for 8 awards that are funded over 39 months (three academic years plus some lead-in time). The total awards will be for a maximum of $4 million for single institutions and $6 million for consortia of institutions. All four-year institutions and universities are eligible to apply.

These FOAs bring the total spending on HIT workforce development to an impressive total of $118 million:
  • Community college consortia - $70 million
  • Curriculum development centers - $10 million
  • University-based training - $32 million
  • Workforce competency assessment - $6 million
I will devote the rest of this posting to the university training FOA. Individuals trained by the programs funded through this FOA will assume more highly specialized roles and serve as leaders in supporting the meaningful use of HIT. The training will cover six workforce roles identified 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
The FOA states that the roles listed are not rigidly defined purposefully because the field is evolving. This will give programs the ability to create new and creative approaches to educating these individuals. Of note is that there is a clear role for public health positions and not just for individuals in healthcare. Applications must describe job titles and key responsibilities that the training for these roles will fill.

Priority for funding will be given to institutions that already have existing baccalaureate, certificate, or master’s degree programs. Institutions must address at least three, and preferably more up to all six, job roles. Applications will be accepted from universities that both plan to expand their existing programs as well as create new ones.

Funding will only support “new students,” defined as those not enrolled in an HIT educational program on the date that the FOA was published, which is December 17, 2009.

Programs will be funded for 39 months (3 years, 3 months), starting in 2010, to allow three cycles of academic years. The first academic year must begin with the fall term of 2010.

Two types of students will be supported:
  • Type 1 – programs that can be completed in less than one year, ideally in less than 6 months, leading to a certificate or master’s degree without thesis
  • Type 2 – programs that require more than one year to complete, typically a master’s degree with thesis
Programs must maintain a ratio of five Type 1 students for every Type 2 student. Priority will be given to programs that use “creative and flexible” mechanisms to expand capacity, such as distance learning and part-time enrollment.

The FOA notes that $6,500 per trainee for program development and training related expenses will be awarded for costs associated with faculty and staff salaries, program administration, program-related equipment, faculty travel necessary to successfully implement the program, and trainee child care. It also states that for all types of trainees, the grants will support (up to a fixed maximum) trainee tuition and fees. For trainees in master’s degree programs with a required thesis, funding will additionally support health insurance sponsored or required by the awardee institution and a stipend for each trainee enrolled in the program on a full-time basis. (Although the maximum amount for annual health insurance is $2000, which I note somewhat tongue-in-cheek gives us the maximum incentive to bring about health care reform and cost control as soon as possible!)

Allowable costs include (quoted from the FOA):
  • Developing and revising curricula in medical/health informatics and related disciplines.
  • Recruiting and retaining students to the program involved.
  • Acquiring equipment necessary for student instruction, including the installation of test bed networks for student use.
  • Establishing or enhancing bridge programs in the health informatics field s between community colleges and universities.
  • Faculty release time to prepare for teaching in these programs.
  • Professional salaries for management of the process to create the program.
Tuition and fees for both types of trainees is supported. For Type 1 trainees, up to $10,000 may be budgeted. For Type 2 trainees, up to 60% of regular tuition and fees, not to exceed $16,000 per year, may be budgeted. Type 2 trainees may also receive an annual stipend of $15,000 and annual health insurance coverage of $2,000. F&A costs of 8% of non-tuition expenses may be budgeted.

Evaluation will be consist of close monitoring of a number of milestones in the FOA related to matriculation, graduation, and employment. A mid-award review will take place after the these milestones are compiled after the 18th month of program operation.

An important part of the proposal will be the proposed strategy for the program. It must include the following (quoted from the FOA):
  • The role being addressed and (for consortial programs) the name of the institution that will be home to the program.
  • The overall educational goals for the program.
  • Whether the applicant is proposing to establish a new program or to expand an existing one.
  • The duration of the training and whether a degree or certificate will be awarded. If a degree, specify the degree and which institutional department will award it. If a certificate, specify the proposed title of the certificate and which department will award it.
  • If the program is a new program, when the training program will matriculate its first trainees.
  • Whether the program addresses health care, public health, or both.
  • The target number of trainees to be enrolled in this program per year, and, separately, the number of these trainees to be supported by funds from this grant.
  • The curriculum for the program listing titles and credit hours (or trainee time commitment) of all required courses and other required experiences. For each required course/experience, indicate whether it is currently offered or whether it will require development. Include in an appendix, a brief (approximately 200 word) description of each required course or experience.
  • The faculty members who will be offering the required courses and other experiences. Biosketches for these faculty members must be included in a separate section of the application.
  • Mechanisms for student mentoring and advising, also specifying how trainees’ progress through the program will be monitored and evaluated.
  • If the program requires supervised research or scholarship (a terminal project, thesis, or dissertation), a description of the resources that will be available to students as venues for this work.
The four collective FOAs represent a comprehensive and well-resourced approach to growing the HIT workforce. A $118 million investment in HIT workforce is an excellent expenditure of economic recovery funds. I will have more to say in the future but for now I need to start my proposal writing!

Sunday, December 6, 2009

Section 3016 Has Arrived!

The long-anticipated Funding Opportunity Announcements (FOAs) for health information technology (HIT) workforce development, as specified in Section 3016 of the American Recovery and Reinvestment Act (ARRA), have been released by the Office of the National Coordinator for Health IT (ONC). These FOAs reveal the overall plans of ONC for quickly ramping up the workforce to meet the ARRA electronic health record (EHR) adoption goals. This will be done by two specific FOAs, one that funds development of five regional consortia of community colleges around the country, who in turn will implement curricula developed by the other FOA that funds five national curriculum development centers.

ONC has also provided its own analysis and plan for the workforce. Both FOAs state a need to train 51,000 workers to implement the ARRA HIT agenda. They list specifically six job roles for this workforce, noting that preparation for any them will typically require six months of intense training for individuals with appropriate backgrounds. These individuals could work for a variety of entities, including health care organizations, regional extension centers, government organizations, vendors, and others. (It would be great for those of us with an interest in workforce research and education to see their data and analysis of the workforce needs. I hope they release it at some point.)

Four of the job roles are "mobile adoption support positions" and involve personnel who carry out the initial EHR implementation at a site and then move on to the next one. The specific roles for these positions are:
  • Practice workflow and information management redesign specialists
  • Clinician/practitioner consultants
  • Implementation support specialists
  • Implementation managers
The other two job roles are "permanent staff of healthcare delivery and public health sites" and provide ongoing support after implementation. The specific roles for these positions include:
  • Technical/software support staff
  • Trainers
Although this process presents a coherent and specific plan to quickly ramp up the workforce, an approach with which I concur, I also hope it also raises the visibility of clinical informatics as an important component of EHR adoption and a career option for people who aspire to work professionally (and academically) in HIT. I am somewhat disappointed that the programs developed will not have pathways that articulate with more formal degree programs (e.g., baccalaureate and master's degrees, or even associate degrees for that matter). I do hope that educators who participate will be given the option to find ways to make further articulation and career enhancement happen. In addition, while I know that community colleges have historically risen to the challenge of quickly implementing skills-based training, I also wonder whether those with no experience or expertise teaching this content will be able to ramp up quickly enough. Where, for example, will they find faculty with sufficient expertise to do more than just deliver a packaged curriculum?

One also has to wonder whether those with short-term training will have the complex array of knowledge and skills in areas like healthcare workflow, change management, quality measurement, and oral and written communication (among even more) that are so essential for successful EHR implementation in complicated entities like healthcare organizations. We will no doubt be witnessing a great workforce and education "experiment" (just like, I suppose, all of the ARRA EHR agenda). I look forward to being a "subject" in that experiment.

On to the details. The first FOA (EP-HIT-10-001) is entitled, Community College Consortia to Educate Health Information Technology Professionals in Health Care Program. This FOA divides the country into five regions, each of which will have one consortium. Each consortium has a target amount of funding, number of students, and number of institutions. (Oregon is in Region A, the smallest of the five regions in terms of population served.) The overall allocation is $70 million.

Each consortium will have a lead organization and targeted number of member community colleges (varying from 5-8 in Region A to 17-23 in Region E in the Northeast). Each will have an expected minimum number of students each year, with the overall goal of training 10,500 students annually. Programs will not award degrees, but instead award a six-month certificate. It is assumed many students will have some background in healthcare and/or IT, and will need to flexibly learn more of what they do not know. Each member institution does not have to offer training for all six job roles, but each consortium as a whole must cover all the roles. The number of institutions must be within the specified range (unless an exemption is given), though each member does not need to train an equal numbers of students. Training must be commence by September 30, 2010.

Funding is for two years. The FOA does not address sustainability, either as requiring it in the plan or its being assessed in evaluation of proposals. It does say that the funding is a one-time opportunity. Up to $1M per consortium can be budgeted for consortium expenses. Up to 8% indirect (F&A) costs will be awarded to the lead institution and any others that have federal F&A agreements. My reading of the FOA is that any institution of higher learning, including a university, that offers HIT training (e.g., OHSU) can be a lead institution. The amount of funding works out to about $3,000-$4,000 per student trained (depending on the region and how much is allocated for consortium expenses).

The second FOA (EP-HIT-10-003) is entitled, Curriculum Development Centers Program. The goal of this FOA is to develop curricula that will be deployed by the community college consortia formed in the other FOA to train HIT professionals in 20 topics the cover the six specific job roles.

This FOA will fund five centers to develop materials in some number (applicants need to specify 7-10 where they have expertise) of areas from a list of 20. They are required to be academic training programs in informatics, HIT, or HIM, and engage both community college educators as well as instructional design experts. One center will also be designated the National Training and Dissemination Center, and additionally carry out training as well as establishing the repository for download of materials.

Each center will be funded up to $1.82M over two years ($910,000 per year), including indirect costs. The National Training and Dissemination Center will receive an additional $900,000 ($450,000 per year), including indirect costs.

Like the other FOA, there is a great amount of prescriptive detail provided. The 20 curricular areas from which to choose include:
  • 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
This whole approach is not without risk, but as I said above, it is a great plan for quickly ramping up the workforce. I do hope that it will allow for professional growth and development for those undertake the training and want to work as professionals in this extremely important component of improving healthcare. I also hope that the process will be evaluated well, so we can make corrections to the process when we find areas it does not work. In any case, I will stop writing now and get back to working on my proposals!

Saturday, December 5, 2009

Two new international workforce studies

Things are really heating up in the health information technology (HIT) workforce arena! Not only have two new workforce analyses from abroad been published, but in the US, the long-anticipated Funding Opportunity Announcements (FOAs) for HIT workforce development, as specified in Section 3016 of the American Recovery and Reinvestment Act (ARRA), have been released by the Office of the National Coordinator for Health IT (ONC).

The first workforce study comes from Australia (Legg, M. and Lovelock, B., 2009. A Review of the Australian Health Informatics Workforce. Melbourne, Australia: Health Informatics Society of Australia). Commissioned by the Health Informatics Society of Australia (HISA), this analysis looked at the "health informatics" workforce in that country. The authors defined health informatics for the purposes of its analysis, although also noted that this definition was likely incomplete. The study was carried out in two steps consisting of two focused workshops with a small number of people and then a larger survey that was distributed to all members and anyone who ever participated in any HISA activity. A total of 1,279 (out of 6,434 possible) people completed the latter.

The study classified jobs into two broad categories:
  1. Those who work "in the system," e.g., to use their words: records, analysis, direct, decision, communications, and training
  2. Those who work "on the system," e.g., to use their words: systems, infostructure, improvement, education, resource, and administration
The study characterized the work of these individuals by categories (many performed more than one) and also captured data on perceived needs for education, training, and expansion of the workforce. The authors concluded with a number of recommendations for expansion and improvement of the workforce.

On the issue of workforce size, the authors made several estimates, all of which came out with a relatively consistent range. This included the use of government employment statistics for health information management and IT professionals in health care. The authors also made a quick calculation based on my own previous research (of other research studies) finding a ratio of 1 IT worker per 50 non-IT workers in healthcare settings. The bottom line is an estimate of around 12,000 health informatics professionals (range 9,000-15,000) in a country with a population of approximately 21 million. (This number is not that far off the proportionate number of people identified for the United States in my HIMSS Analytics Database study, i.e., 108,390 IT personnel, perhaps along with 10,000 informaticians and 50,000 need for the ARRA EHR agenda, in a country of over 300 million.)

The study also reported that participants consistently expressed concern about a pending shortage of personnel, for which the authors proposed a number of solutions. These included efforts to increase the supply of workers through training and re-training, improving their productivity, and reducing demand through better design of systems and processes.

The second workforce study comes from Canada (O'Grady, J., 2009. Health Informatics and Health Information Management: Human Resources Report. Toronto, Ontario, Prism Economics and Analysis). It focused on professionals defined as working in the fields of health informatics and health information management . This study attempted to characterize job roles and activities, quantify the workforce, and anticipate future needs based on low, medium, and high growth scenarios. (They also noted that Canada was similar to the US and different from most Western European countries in being a laggard in the adoption of HIT.) Similar to other studies, they used a variety of techniques, including government employment statistics. They calculated needs based not only on growth in use of HIT but also replacement of those retiring or otherwise leaving the workforce.

The study looked at seven categories of workers, assessing job roles and specific challenges for each. In aggregate, the authors estimated current HIT employment in Canada at 32,450, broken down among the job categories as follows (approximately):
  1. Information Technology - public sector 11,000-13,000, private sector 5,000-6,000
  2. Health Information Management - 4,300-5,800
  3. Canadian Health System Management and Administration (counted in Analysis and Evaluation)
  4. Project Management - public sector 760-900, private sector 1,100-1,300
  5. Organizational and Behavioral Management - public sector 1,100-1,300, private sector 1,900-2,300
  6. Analysis and Evaluation - 3,300-3,900
  7. Clinical Informatics - public sector 600-710, private sector 380-450
The growth scenarios were based on the following (interesting) assumptions:
  • Low growth - across the board expenditure cuts by the Canadian health system
  • Medium growth - deferring of some capital investments
  • High growth - HIT investment unaffected by changes in health care spending
The cumulative employment growth for all categories combined to 2014 would then be:
  • Low growth - 7.6% growth to 35,020
  • Medium growth - 14.3% growth to 37,200
  • High growth - 26.1% growth to 41,030
For a country with a population of 33 million, these numbers are similarly proportionate to the Australian and US data!

The study also noted that Canada, like most countries, will face a substantial training need for many current and future personnel. Not only does 27% of the current 2009 workforce require additional formal training and experience, but 39%, 59%, or 78% of the 2014 workforce will require additional training under the low, medium, and high growth scenarios respectively.

So clearly Australia and Canada have major HIT training needs. Of course, so does the United States, as noted by my HIMSS Analytics Database study as well as recent estimates by ONC. To that end, two FOAs were recently released by the ONC to address workforce needs, as specified by Section 3016. These will be addressed in another posting soon.