Sunday, September 18, 2022

A New Pathway for My Career in Biomedical and Health Informatics

This year, 2022, marks a quarter-century of my leadership of academic informatics at Oregon Health & Science University (OHSU). I have served for 19 years as the one and only Chair of the Department of Medical Informatics & Clinical Epidemiology (DMICE) in the OHSU School of Medicine. I served six years before that as Head of its predecessor free-standing Division of Medical Informatics & Outcomes Research, which was established in 1997.

I now plan to step down as Chair of DMICE while continuing at OHSU as a Professor in DMICE, focusing my activities on research, education, writing, and mentoring. I will support the new Chair and prioritize the continued success of the department.

I am pleased to hand off the department at a time when it is doing well academically and financially. The faculty are productive and well-funded in their research, and our educational programs continue to attract strong enrollment and prepare students for diverse careers in our field.

My own research and educational activities are also productive and well-funded. I plan to continue my research in applying information retrieval (IR, also known as search) methods to tasks such as patient cohort discovery though data from the electronic health record (EHR) for which I am funded with an R01 grant from the National Library of Medicine. I also intend to continue working in the evaluation of machine learning for clinical applications, mainly focused on diagnosis of rare diseases through EHR data.

I will also continue teaching both in the OHSU Biomedical Informatics Graduate Program as well as in external collaborations, such as with the American Medical Informatics Association (AMIA) in the 10x10 ("ten by ten") program and the Clinical Informatics Board Review Course (CIBRC). I will also continue existing and new National Institutes of Health (NIH)-funded educational activities, including our recently renewed NLM T15 Training Grant, a new NLM R25 establishing a new college summer internship for students historically underrepresented in our field, the Data Science Initiative for Africa in collaboration with the University of Cape Town, and the new Bridge2AI Program.

Saturday, August 13, 2022

Arrival of 8th Edition of Health Informatics: Practical Guide

I am pleased to announce publication of the 8th Edition of Health Informatics: Practical Guide. The goal of this textbook is to provide a comprehensive introduction to the field of health informatics (also known as biomedical and health informatics or just plain informatics) for students. The book can also serve as a current update for those who are already practitioners. As in any professional field, there is a knowledge base and history of scientific progress in informatics that informs current practice, and this book aims to impart that.

The impetus for this book came from Robert Hoyt, MD, who served as its lead Editor for the first seven editions. In preparing the seventh edition, Dr. Hoyt engaged me as a Co-Editor, with the plan for me to become the Editor of the 8th edition. Dr. Hoyt and his wife Ann Yoshihashi, MD have been great mentors in the process of putting a book like this together. As with the previous editions, the book is available in print and eBook formats.

This book is aimed at those who wish to learn about the field of biomedical and health informatics. The content is almost completely redone from previous editions and roughly follows a course I have taught for three decades to about 5000 students in a graduate course at Oregon Health & Science University, the American Medical Informatics Association 10x10 ("ten by ten") program, and a number of other derivative courses for medical students, graduate students, and health IT professionals. I have engaged a variety of other authors for many of the chapters to give additional expertise and perspective. This edition of the book is completely rewritten from earlier editions, reflecting the profound change and progress in the field.

I have established a Web site for the book, which has links to purchasing the book in print and eBook formats from the publisher, Lulu.com. The book is also available from Amazon.com in print and Kindle formats. The Web site also contains sample chapters in PDF and EPUB formats, and will maintain an Errata page of errors discovered in the book.

The chapters of the book include:

  1. Introduction to Biomedical and Health Informatics
  2. A Short History of Biomedical and Health Informatics
  3. Computing Concepts for Biomedicine and Health
  4. Electronic Health Records
  5. Standards and Interoperability
  6. Data Science and Artificial Intelligence
  7. Clinical Decision Support
  8. Natural Language Processing
  9. The Role of Health Informatics in Safety, Quality, and Value
  10. Health Information Exchange (HIE)
  11. EHR System Selection and Implementation
  12. Telemedicine and Telehealth
  13. Privacy and Security
  14. Information Retrieval (Search)
  15. Clinical Research Informatics
  16. Translational Bioinformatics
  17. Nursing Informatics
  18. Consumer Health Informatics
  19. Public Health Informatics
  20. Evidence-Based Medicine
  21. Imaging Informatics
  22. Ethical Issues in Health Informatics
  23. Human-Computer Interaction

Friday, July 1, 2022

Reflections on Publishing a Negative Study

Although scientists are supposed to be disinterested observers of the results of their work, the reality is that none of us really want to see a negative result from our research. This is especially the case in fields like biomedical and health informatics, where we aim to develop tools that can be used to help patients and/or clinicians with their health or for delivery of care.  Nonetheless, it is critically important to publish such outcomes, especially if the research was methodologically sound. This is especially the case in currently hyped technologies such as machine learning.

One of the challenges for negative studies is the myriad of potential reasons why they failed, which sometimes makes the true reason hard to pinpoint. Was it poor methods, inadequate data, or mis-application of the technology? Or more than one of those? But especially in the case of studies that involve human subjects who may be exposing themselves to risk, we must always remember the words of noted physician-scientist Iain Chalmers, who stated that failure to publish studies with patients is a form of scientific misconduct.(1)

A couple years ago, my colleague Aaron Cohen and I received some funding from a pharmaceutical company that had developed a highly effective new treatment for a rare disease, acute intermittent porphyria (AIP).(2) The new treatment, although expensive, significantly reduces the severe and sometimes disabling manifestations of AIP. As such, tools to identify patients who might have the disease could significantly improve their lives. Our approach used data from their electronic health record (EHR).

We were thrilled when our machine learning model was found to identify a group of patients with the classic presentation of AIP, yet the diagnosis had never been considered.(3) AIP is known to be one of those rare diseases that often goes undiagnosed for long periods of time. Diagnosis of these types of rare diseases is considered to be a major use case for machine learning in healthcare. From a collection of over 200,000 patient records in the research data warehouse at our institution, we manually reviewed the top 100 ranking patients identified by the model. Twenty-two of these patients were determined to have the manifestations of AIP but with no occurrence of the string "porph" anywhere in their record, i.e., not in lab tests, notes, or diagnoses. As the test to diagnose AHP is a relatively simple and inexpensive urine porphobilinogen test, we developed a clinical protocol to invite such patients for testing.

We encountered a number of challenges in developing and implementing the clinical protocol. For example, what is the role of the patient's primary care or other provider in the decision to offer testing? Our institutional review board (IRB) determined that the process should a decision by the provider, who would then allow us to contact the patient to offer testing. Once given approval by the provider, we then had to convince the patients, many of them skeptical of the healthcare system long unable to diagnose their symptoms, to come in for testing. Another challenge in implementing the protocol was that it took place during the COVID-19 pandemic, when many people wanted to avoid healthcare settings, though by the time we were recruiting patients, the COVID-19 vaccines had started to become available.

As a result, we could only convince 7 of the 22 patients to undergo the simple and free test we were offering them. And as noted in the paper, none of them were positive.(4) Because these patients did submit to a clinical protocol, and because we believe that any attempt to clinically validate machine learning is important, we decided to submit our results to a journal as a Brief Communication, i.e., not the definitive study but clearly worth reporting. The report has now been published.

Clearly there are many possible reasons for our failure to diagnose any new cases of AIP. Not the least of these is the fact that AIP is a rare disease, and there may have been few if any new cases to be found. Certainly if we had more resources or time, we could have invited for testing more people beyond the first 100 cases we evaluated who may also have been found to have the classic presentation yet for whom the diagnosis was never considered. It is also possible that our machine learning model could have been better at identifying true cases of the disease. There may have been confounders in that those actually coming for testing were not the most likely to have the diagnosis.

Could this study have benefited from proactive genotyping? There may be a role for gene sequencing in this situation, but AIP is a condition of incomplete penetrance, i.e., just because one has the genotype does not mean they will develop the manifestations of the disease. In other words, genotyping would not be enough.

My main hope is that this contribution shows that we should be pursuing such studies aiming to apply machine learning in real-world clinical settings. As one who has been critical that machine learning has not been "translational" enough, I hope there will be a role for larger and more comprehensive studies of many different uses that have been found to be beneficial in model-building studies.

References

1. Chalmers, I., 1990. Underreporting research is scientific misconduct. JAMA 263, 1405–1408.

2. Balwani, M., Sardh, E., Ventura, P., Peiró, P.A., Rees, D.C., Stölzel, U., Bissell, D.M., Bonkovsky, H.L., Windyga, J., Anderson, K.E., Parker, C., Silver, S.M., Keel, S.B., Wang, J.-D., Stein, P.E., Harper, P., Vassiliou, D., Wang, B., Phillips, J., Ivanova, A., Langendonk, J.G., Kauppinen, R., Minder, E., Horie, Y., Penz, C., Chen, J., Liu, S., Ko, J.J., Sweetser, M.T., Garg, P., Vaishnaw, A., Kim, J.B., Simon, A.R., Gouya, L., ENVISION Investigators, 2020. Phase 3 Trial of RNAi Therapeutic Givosiran for Acute Intermittent Porphyria. N Engl J Med 382, 2289–2301.

3. Cohen, A.M., Chamberlin, S., Deloughery, T., Nguyen, M., Bedrick, S., Meninger, S., Ko, J.J., Amin, J.J., Wei, A.J., Hersh, W., 2020. Detecting rare diseases in electronic health records using machine learning and knowledge engineering: Case study of acute hepatic porphyria. PLoS ONE 15, e0235574.

4. Hersh, W.R., Cohen, A.M., Nguyen, M.M., Bensching, K.L., Deloughery, T.G., 2022. Clinical study applying machine learning to detect a rare disease: results and lessons learned. JAMIA Open 5, ooac053.

Wednesday, June 29, 2022

2022 Update of Informatics.Health

I am pleased to announce an update of my Web site that provides an introductory overview of biomedical and health informatics. Entitled, What is Biomedical & Health Informatics?, I created this site two decades ago to provide an answer to that question I used to be asked (less so in modern times). I still maintain and keep the site up to date both to continue to provide an overview of the field as well as demonstrate a portfolio of some of the learning technology we use in our virtual courses in the Biomedical Informatics Graduate Program at Oregon Health & Science University (OHSU).

In recent years I was able to secure the domain name, Informatics.Health.

With the 2022 updating of my larger course that is offered in the American Medical Informatics Association (AMIA) 10x10 ("ten by ten") program, I have now updated the content of the WhatIs site. The main part of the site is the 11 lecture segments on the following topics:

  • What is Biomedical and Health Informatics? (1) (24:32)
  • What is Biomedical and Health Informatics? (2) (18:49)
  • A Short History of Biomedical and Health Informatics (22:30)
  • Resources for Field: Organizations, Information, Education (25:29)
  • Clinical Data (15:08)
  • Examples of the Electronic Health Record (EHR) (24:56)
  • Data Science and Artificial Intelligence (1) (14:15)
  • Data Science and Artificial Intelligence (2) (22:07)
  • Information Retrieval (Search) (23:18)
  • Information Retrieval Content (29:09)

The lectures can be viewed on just about any Web platform, and work fine on mobile devices. The site also contains links to books, articles, organizations, and educational Web sites. The materials on the site are freely available and have been used by many educators and others.

Wednesday, April 6, 2022

3000 by 2022 - A New Milestone for the 10x10 Course

One of the most enjoyable and impactful activities of my career has been the 10x10 ("ten by ten") course, which is an online introductory course in biomedical and health informatics that I teach in partnership with the American Medical Informatics Association (AMIA). The course recently reached a new milestone, surpassing 3000 people completing the course since its inception in 2005. My course from Oregon Health & Science University (OHSU) was the original and is the largest course of the AMIA 10x10 Program.

The OHSU 10x10 course provides an up-to-date detailed introductory overview of biomedical and health informatics. The content delivery is online, followed by an optional in-person session, typically at an AMIA meeting, at its conclusion. About 10-15% of those completing the course take the optional final exam and pursue further study in the field, usually but not exclusively at OHSU.

The 10x10 program gets its name from the program's original goal in 2005 to train 10,000 people in biomedical and health informatics by the year 2010. The goal for 10,000 people came from a stated need by then-President of AMIA Dr. Charles Safran that there should be at least one physician and one nurse trained in informatics in each of the approximately 6000 hospitals in the US. I adapted an already-existing online introductory informatics course and we set the goal of 10,000 people completing the course by 2010, leading me to devise the moniker, 10x10. Even though 10,000 people did not come forward to take the course by 2010, about 1000 people did complete the OHSU offering by 2010.
 
After 2010, the 10x10 program continued to attract enrollment. The positive feedback of those completing the course has always been gratifying. Now, a new milestone has been reached with the cohort who recently completed the course, surpassing a total of 3000 individuals having completed the OHSU 10x10 course since 2005. A total of 111 offerings of the OHSU course have been provided since that time. While most of the course enrollment has come from the US, several international organizations have partnered to offer the course based in their countries, including Gateway Consulting (Singapore), King Saud University (Saudi Arabia), the Ministry of Health (Israel), and Abu Dhabi Health Services (SEHA, United Arab Emirates). There have also been partnerships to offer the course with domestic organizations in the US, including the American College of Emergency Physicians, the Academy of Nutrition and Dietetics (AND), the New York State Academy of Family Practice, the Mayo Clinic, the Centers for Disease Control and Prevention, and others. The table below shows the course partners, the number of offerings with them, and the number of people completing the course.
 
 
The figure below shows the enrollment by year. The largest amount of enrollment came during the heyday of the "meaningful use" era in the early 2010s, dipped somewhat later in the decade, but has continued strong since then.

 
Due to the online delivery of the course, it had no trouble continuing during the COVID-19 pandemic, although the in-person sessions at the end of the course were transitioned to virtual delivery. With the receding of the pandemic, those sessions have returned now to an in-person format. Of course, the content of the course was affected by the pandemic and its impacts on the field. However, the more fundamental topics of the field, including electronic health records, standards and interoperability, machine learning and artificial intelligence, and others have still been covered in a comprehensive and up-to-date manner.

The course will continue to be offered beyond this milestone, and in fact a new offering is beginning this month. In-person sessions for those completing the course will take place at upcoming AMIA meetings this year, including the Clinical Informatics Conference (Houston, TX - May 23-26) and the Annual Symposium (Washington, DC - November 5-9).

As the OHSU agreement with AMIA is non-mutually-exclusive (i.e., AMIA can offer other 10x10 courses and OHSU can use the course materials in other courses), the content of the OHSU 10x10 course has been delivered to students under other course names. The other major use of the content is in the course, BMI 510/610, which is the introductory course in the Health & Clinical Informatics Major of the OHSU Biomedical Informatics Graduate Program. This course has been offered since the OHSU graduate program was launched in 1996 and every academic quarter since 2000. After the most recent academic term, 1598 people have completed this instance of the course.

The course content was also converted into a virtual two-week block course for medical students at the onset of the pandemic. The course was made available to medical students within and outside OHSU, with 44 OHSU medical students participating in three offerings and 178 medical students from outside OHSU participating in eight offerings during 2020. This block course continues to be offered to OHSU medical students.
 
Other offerings of the course have been provided to health systems, including Kaiser Permanente Northwest, Providence Health and Systems, and Bangkok (Thailand) Hospital. The course has also been offered to H3ABioNet, the Pan African Bioinformatics Network for the Human Heredity and Health in Africa (H3Africa) consortium, of which I serve on the Scientific Advisory Board.
 
The course  also inspired federal legislation in the US, leading to the 10,000 Trained by 2010 Act, introduced by Rep. David Wu (D-OR). The bill was passed by the US House in the 111th Congress (2009-2010), and elements of it were incorporated into the HITECH Act. The HITECH program included funding for Health IT Workforce Development, including grants awarded to OHSU.

Probably the most gratifying aspect of the course is the feedback I get from students who appreciate the broad but sufficiently deep content, i.e., getting the big picture while also learning the rationale behind it. I enjoy keeping in touch with those who have taken the course, especially when I run into them in airports, at conferences, or other places. I also value the motivation that the course provides to me in keeping up with advances across the entire field of biomedical and health informatics.

Friday, March 25, 2022

Clinical Informatics Subspecialty Practice Pathway Extended for Three Additional Years

A three-year extension to the Practice Pathway of board certification eligibility for the clinical informatics (CI) subspecialty has been approved by the American Board of Medical Specialties (ABMS) for the American Board of Preventive Medicine (ABPM). This is the second extension of the so-called "grandfathering" pathway that now allows physicians with a primary boarded specialty to achieve board eligibility without formal fellowship training through 2025. This means that physicians who desire to become board-certified in CI will be able to qualify to sit for the board examination by time working in the field or completing "non-traditional" training, the latter which may include a master's degree from a "24 month Masters or PhD program in Biomedical Informatics, Health Sciences Informatics, Clinical Informatics, or a related subject from a university/college in the US and Canada, deemed acceptable by ABPM (e.g. NLM university-based Biomedical Informatics Training)," such as the online Master of Science Program at Oregon Health & Science University (OHSU).

The CI field has expressed mixed feelings on this extension. In particular, a group of CI fellowship Program Directors published a letter in the journal Applied Clinical Informatics (ACI) opposing the extension, noting that the time for grandfathering has passed, and extending the practice pathway will adversely impact pursuit of fellowships.[1] I rebutted this letter, arguing that the field must find alternatives to two-year in-place fellowships to allow broader entry into the field.[2] In particular, a two-year in-place fellowship may place undue burdens on those who wish to become board-certified in CI long after they completed their primary training and would be unable to uproot from job, family, and/or other obligations.

Here are some snippets from my ACI letter arguing for alternatives to in-place fellowships:

I agree that we have passed the point where the Practice Pathway should allow physicians to become board-certified with essentially no formal training. However, I argue instead for this approach to be transformed into a method by where those who are unable to halt careers, salary, and family to pursue a pathway to certification that is mostly virtual and asynchronous yet still rigorous and supervised. Ironically, the pandemic has taught us that CI practice and education can be carried out in a mostly virtual format.

The in-place model for fellowship training made sense in the 20th century model of career development, where one completed education and training in their chosen profession and then entered the workforce for their career. In the 21st century, however, many professionals, especially in knowledge careers, change career pathways long after their primary education and training experience.

I oppose CI fellowships being completely remote, but it would be novel and innovative if there were some sort of hybrid training pathway, with fellows connected to an institution that could offer courses and allow supervised, mentored training experiences in healthcare organizations. Fellows would participate in a mostly remote way, but also have periodic in-person experiences, including stints that might be for several weeks or more and would involve direct interaction with faculty and colleagues. The field of Hospice and Palliative Medicine developed such an approach prior to the COVID-19 pandemic. Even CI somewhat emulates this approach now, as a half-dozen CI fellowships make use of online didactic courses from OHSU.

I applaud that for now the Practice Pathway will still allow those to pursue board certification. Hopefully the CI field can transition to a training process beyond the Practice Pathway that allows entry into the field without an in-place fellowship. As informaticians, we should be at the forefront of pioneering this approach in graduate medical education.

What are eligibility requirements for the CI subspecialty? They are essentially unchanged from the last time I posted about them in this blog in 2019, with the exception that the "grandfathering" pathway is now available through 2025.

References

1. Turer, R.W., Levy, B.P., Hron, J.D., Pageler, N.M., Mize, D.E., Kim, E., Lehmann, C.U., 2022. An Open Letter Arguing for Closure of the Practice Pathway for Clinical Informatics Medical Subspecialty Certification. Appl Clin Inform 13, 301–303. https://doi.org/10.1055/s-0042-1744386.
 
2. Hersh, W.R., 2022. The Clinical Informatics Practice Pathway Should Be Maintained for Now but Transformed into an Alternative to In-Place Fellowships. Appl Clin Inform 13, 398–399. https://doi.org/10.1055/s-0042-1745722.

Friday, March 11, 2022

Receding of the Pandemic: Will the Third Time Be the Charm?

Today, the Governor of Oregon is lifting the state's indoor mask mandate and ending the state's public health COVID-19 emergency. Like most US states, Oregon had a large Omicron wave of cases, hospitalizations, and deaths, although as through all of the pandemic still far below US national averages. At Oregon Health & Science University (OHSU), the number of patients in the hospital and ICU continues to fall each day. The mask mandate in non-healthcare buildings at OHSU will be dropped tomorrow and my department will return to some activities in-person with the start of the spring quarter at the end of March.

Will the pandemic finally recede now and allow us to return to an albeit new normal? We have been down this road before. The first came in the late spring and early summer of 2021. Vaccination had become relatively widespread, and the large wave of hospitalizations and mortality from late 2020 and early 2021 appeared to be subsiding. In Oregon, all mask and other public health mandates were lifted, and life seemed to be returning to normal.
 
Sadly, however, the Delta wave started in the late summer of 2021 and dashed hopes that the fall would see a return to relative normal. As the Delta wave subsided in the late fall, a second era of opportunity seemed to be coming again. Although somewhat more muted than the first reprieve, it looked as if a modified normal might occur in early 2022.

But then, of course, Omicron came, and with it a new wave of hospitalizations and mortality. One fortunate aspect of the Omicron wave is that there has been clear evidence that vaccination provides protection. Even if not preventing SARS-CoV-2 infection completely, vaccination does appear to limit the worst of the infection for most people.

Now the Omicron wave is receding, and hopefully the worst of the pandemic with it. Although some might be gun-shy to feel optimistic, it is clear that there can be a path to living with the virus and a new approach that balances public health requirements with individualizing risk. I look to those physician experts who express cautious optimism and allowing of individual decision-making within the extremes of those at the ends of the spectrum. My favorites include Ashish Jha, Bob Wachter, Leana Wen, and of course the prolific Eric Topol. I also believe that the federal government's new COVID-19 plan is reasonable, with its emphasis on vaccination, testing, and treatment. This is especially the case with new oral anti-viral treatments shown to be highly effective.

The most unfortunate aspects of this pandemic has been its politicization, it becoming part of the culture wars in the US. I am not unsympathetic to those who want to move on. I do not particularly enjoy wearing masks, even though I do so and will continue doing so when it is necessary to protect myself or others. It saddens me that one of the most speedy and effective vaccines ever developed is being met by so much resistance. In addition, the manipulation and misinformation is saddening for a medium I always hoped would lead to dissemination of communication and knowledge across humanity. Wishful thinking, I suppose.

I find particularly sad the misunderstanding of science and the gotcha politics of when knowledge changes based on new research. One of the best quotes comes from Mohamad Safa, an environmental activist who stated on Twitter: "Science is not truth. Science is finding the truth. When science changes its opinion, it didn't lie to you. It learned more."

As the pandemic recedes, what will be my approach? Being relatively healthy and in my early 60s, I would probably weather a COVID-19 infection reasonably well. I will not go out looking for one, but I also will not have dire fear of getting one. One irony about the pandemic period is that I have not been infected so much as a cold, which I normally get once to twice per year. I will also respect the public health concerns for COVID-19. I will not hesitate to wear a mask when I am asked to do so, especially when it protects someone who might be at higher risk of complications from infection. I will also continue to join the chorus of those advocating for more vaccine equity across the world.

The months ahead will be a large natural experiment in the United States, as mandates are lifted. We will see whether the collective immunity we have achieved through vaccination and natural infection will be enough to keep SARS-CoV-2 under control, especially those at highest risk of complications from infection.

Tuesday, January 11, 2022

Considerations and Transitions for Narrating Lecture Slides

For over two decades, a significant portion of my teaching at Oregon Health & Science University (OHSU) has been online, and one of the main modalities I have used is narrated lectures, in particular, voice-over-Powerpoint slides. I know that many bemoan the use of Powerpoint for any presentations, including teaching. However, I find slides a very useful way to organize information, utilize simple graphics, and develop a big picture for the knowledge I aim to convey. As I use my teaching slides for other purposes, such as giving talks, another critical need for me is to maintain the source Powerpoint files.

This makes my choice of tool(s) to create voice-over-Powerpoint files critically important in my work. Over the years, I have used different tools for doing so. My initial foray used a technology that some Internet long-timers might remember, called RealMedia. Another imperative in the early days, circa 1999, was that the files not be too large so as not to require substantial bandwidth, since those were the early days of broadband Internet, and many people were still connecting, especially from home, via telephone modems.

Another lesson learned in those early days was that learners preferred online lectures to be broken down into 15-20 minute segments. This also made recording easier, as one did not have to record an entire lecture in a single session.

Over time, there was development of new tools. RealMedia eventually fell out of favor with many users and developers, and for a while I used a now-defunct tool from Adobe called Presenter. It used an output format that was very popular for many years, Flash, which was retired a few years ago.

In 2007, I discovered another tool that served me well for a long time, Articulate Presenter. One of its key features was the ability to record a single slide at a time. All of the tools I used before then required the lecture over the whole slide deck to be recorded in a single session. Being able to record slide by slide was useful for several reasons, not the least of which was that most of my updating of curricular content involved incremental update of single slides and not the entire lecture segment. In other words, a small part of a topic might change, and by being able to update individual slides, I could update just those slides than needed it.

Another feature I valued from Articulate Presenter was being able to configure the output with a navigation and notes frame on the left, enabling individuals slides to navigate to specific slides, and for the text in the notes field of the slides to be viewed. The output was generated in Flash when it was in its heyday. and then transitioned to HTML 5 as Flash was being retired.

But there is one big limitation of Articulate Presenter, which is that it only runs on Microsoft Windows. My primary computer when I started using Articulate Presenter was a Windows PC, but in the early 2010s, I was feeling the pull to return to the Macintosh platform that I had moved away from in the mid-1990s. Part of the allure was that Apple itself was transitioning to Intel chips, meaning that Macintosh computers could run Windows and its applications.

I made the transition back to the Mac in 2012, and fairly seamlessly moved my Articulate Presenter work to running Windows on Parallels. But although the solution worked, it was somewhat clunky, and having to launch Windows to do any work in Articulate Presenter required a number of steps. Despite the protestations of myself and many other users (evidenced in their support forums), Articulate never developed a native Mac version of Presenter.

In the last couple years, of course, Apple has transitioned away from Intel chips. This is a good thing for Mac users generally, as the speed and power consumption is remarkable. And while there is supposedly a version of Windows that runs on the ARM chips that Apple is now using, it does not run most native applications, including Articulate Presenter.

Fortunately during this same time, Microsoft has been improving the slide narration capabilities, and one can now easily narrate slide by slide directly in Powerpoint. And then the output can be exported to a standard video format such as MP4 or MOV. In addition, OHSU uses the Echo 360 platform, which allows video files to be posted to a server. While the video output of Powerpoint does not have all the navigation features of Articulate Presenter, the learner can still navigate around the lecture. Echo 360 also offers automated closed-captioning, although it is far from perfect.

This transition will require me to re-record all lectures completely, but many lectures are due for that anyways. In addition, I can record in Powerpoint slide by slide. Using Powerpoint on my Mac is also much less clunky that using Articulate Presenter in Windows on a Mac. It is especially easy when I need to make a small update, such as finding and fixing a typo in a slide, and not having to launch Windows, and then Articulate Presenter.

One can see an example of the results of my new approach in the image below from a Web site that I maintain, What is Biomedical and Health Informatics? I have maintained this site for many years, both as a way to introduce the world to my view of the field of informatics and also a showcase for the online learning modalities that our program uses. The site also has a great domain name I was able to snag when .health was made a top-level domain, http://informatics.health/. I have redone the lectures on this site using my new approach.

Certainly a bottom line is that the ease of updating lectures far outweigh the small additional features provided by Articulate Presenter. It may seem somewhat ironic that improvements in Microsoft Powerpoint now give me the ability to move on from Microsoft Windows and Articulate Presenter. But I am pleased that I can now can evolve with Apple as it innovates its hardware and software with its new ARM chips.