Friday, December 31, 2010

Reflections at the End of Another Amazing Year for Informatics

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.

Friday, December 17, 2010

The Comfort of Connectivity

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.

Wednesday, December 8, 2010

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.

Saturday, November 20, 2010

The Emergence of the Informatics Practitioner

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.

Monday, November 15, 2010

Update on the ONC Workforce Development Program

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.

Tuesday, November 9, 2010

Selected to the Informatics All-Star Team!

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.

Wednesday, October 27, 2010

Health IT Destination: Portland and Oregon

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.

Thursday, October 14, 2010

The Informatics Outlook for Physicians

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.

Tuesday, October 12, 2010

A Teachable Moment About Healthcare Reform and Markets

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.

Thursday, October 7, 2010

New Data Reiterates Coming Need for Health IT Workforce

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.

Thursday, September 30, 2010

New Talk and Department Web Site

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.

Monday, September 27, 2010

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

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.

Friday, September 24, 2010

Welcoming Unprecedented Numbers to the OHSU Informatics Educational Program

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.


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

Sunday, September 12, 2010

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

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.

Friday, August 27, 2010

More Information Available on Meaningful Use

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.

Monday, August 2, 2010

Update on ONC workforce projects

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, 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.

Friday, July 30, 2010

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

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.

Tuesday, July 20, 2010

Meaningful Use Rules Finalized!

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:
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.

Friday, July 9, 2010

Where Are the Jobs? Read While You Wait

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.

Thursday, June 10, 2010

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

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.

Sunday, May 23, 2010

Meaningful Use: A Highly Useful Construct for Informatics

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:
  1. Improve quality, safety and efficiency
  2. Engage patients in their care
  3. Increase coordination of care
  4. Improve the health status of the population
  5. 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.

Saturday, May 15, 2010

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

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

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.