Thursday, December 29, 2011

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

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

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

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

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

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

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

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

I do wish everyone a healthy and prosperous 2012!

Thursday, December 15, 2011

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

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

About Our Program

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

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

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

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

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

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

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

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

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

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

About Our Students

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, November 16, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Postscript: In early 2012, AMIA posted a page of frequently asked questions about the subspecialty:


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

Monday, November 14, 2011

Accolades for the Informatics Professor - Fall, 2010

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

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

Saturday, October 29, 2011

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

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

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

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

Saturday, October 22, 2011

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

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

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

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

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

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

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

Friday, September 23, 2011

Update: Clinical Informatics Subspecialty Approved

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

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

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

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

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

Sunday, September 11, 2011

More Studies Assessing Quality Improvement Using Electronic Health Records

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

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

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

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

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

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

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

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

Monday, September 5, 2011

Update of Site, What is Biomedical & Health Informatics?

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

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

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

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

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

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

Thursday, August 18, 2011

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

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

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

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

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

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

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

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

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

Monday, August 1, 2011

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

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

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

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

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

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

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

Each document contains four sources of information that can be used for the task:
  • Chief complaint
  • Admit diagnosis (as ICD-9 code)
  • Discharge diagnosis(es) (as ICD-9 code)
  • Report text
The documents come from a number of different report types:
  • Radiology Reports - 47,555
  • History and Physical Exams - 15,721
  • Emergency Department Reports - 13,424
  • Progress Notes - 8,538
  • Discharge Summaries - 7,931
  • Operative Reports - 5,032
  • Surgical Pathology Reports - 2,877
  • Cardiology Reports - 632
  • Letter - 1
The task will require relevance assessments for each visit, with retrieval performance measured by recall, precision, and related measures (e.g., mean average precision – MAP) based on the assessments. As with all TREC relevance assessments, retrieved visits will be pooled based on the top N documents for each run of each participating group, where N is a number that will yield a pool of about 300-400 documents for assessment. The test collection will contain 35 topics.

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

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


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

Saturday, July 9, 2011

Sunday, June 26, 2011

National Library of Medicine: An Informatics and Government Agency Exemplar

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

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

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

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

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

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

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

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

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

Friday, June 24, 2011

Public Rollout of the ONC Health IT Curriculum

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

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

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

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

The curricular materials consist of 20 components, each of which is comparable in depth to a college course. The components are subdivided into 8-12 units, each of which contain a variety of activities appropriate to the topic, including voice-over-Powerpoint narrated lectures, references, suggested readings, exercises, and more. The topic areas of the components are: 
  1. Introduction to Health Care and Public Health in the U.S.
  2. The Culture of Health Care
  3. Terminology in Health Care and Public Health Settings
  4. Introduction to Information and Computer Science
  5. History of Health Information Technology in the U.S.
  6. Health Management Information Systems
  7. Working with Health IT Systems
  8. Installation and Maintenance of Health IT Systems
  9. Networking and Health Information Exchange
  10. Fundamentals of Health Workflow Process Analysis & Redesign
  11. Configuring EHRs
  12. Quality Improvement
  13. Public Health IT
  14. Special Topics Course on Vendor-Specific Systems
  15. Usability and Human Factors
  16. Professionalism/Customer Service in the Health Environment
  17. Working in Teams
  18. Planning, Management and Leadership for Health IT
  19. Introduction to Project Management
  20. Training and Instructional Design
ONC and the Curriculum Development Centers also developed a “set table” consisting of a matrix of curriculum components and workforce roles to guide community college programs in using components to train for particular workforce roles. The matrix specified the core set of components for each workforce role for two types of student backgrounds, healthcare and information technology.

Each component also contains a blueprint document that provides an overview of the learning objectives and content for each unit. All of the components also have an instructor's manual that provides more detailed information, including listing of authorship and teaching information. The full set of blueprints have been rolled into a single PDF portfolio and are available on the ONC Web site.

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

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

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

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

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

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

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

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

Tuesday, June 21, 2011

Informatics Destination: Buenos Aires

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

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

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

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

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

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

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

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

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

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

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

Monday, June 6, 2011

Commencement Address Representing OHSU School of Medicine Graduate Studies Program

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

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

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

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

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

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

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

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

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

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

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

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

Sunday, June 5, 2011

An Informatics Silver Lining to a Terrible Tragedy

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

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

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

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

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

Thursday, May 26, 2011

Update on the ONC Curriculum Development Centers Program

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

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

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

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

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

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

The topic areas of the components are: 
  1. Introduction to Health Care and Public Health in the U.S.
  2. The Culture of Health Care
  3. Terminology in Health Care and Public Health Settings
  4. Introduction to Information and Computer Science
  5. History of Health Information Technology in the U.S.
  6. Health Management Information Systems
  7. Working with Health IT Systems*
  8. Installation and Maintenance of Health IT Systems*
  9. Networking and Health Information Exchange
  10. Fundamentals of Health Workflow Process Analysis & Redesign
  11. Configuring EHRs*
  12. Quality Improvement
  13. Public Health IT
  14. Special Topics Course on Vendor-Specific Systems
  15. Usability and Human Factors
  16. Professionalism/Customer Service in the Health Environment
  17. Working in Teams
  18. Planning, Management and Leadership for Health IT
  19. Introduction to Project Management
  20. Training and Instructional Design
Components 7, 8, and 11, denoted with an asterisk* above, are “lab” components that provide hands-on instruction. These components make use of a fully functioning version of the Veteran’s Administration VistA EHR that is included with the curricular materials and can be installed under most flavors of Windows (as well as some Windows virtual machines that run under MacOS and Linux).

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

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

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