Postscripts: Noteworthy Mentions and Links

This posting is devoted to some postscripts on items covered in prior postings.

First, the public rollout of the Health IT Curriculum, funded by Office of the National Coordinator for Health IT (ONC), has received many mentions in the press. Among the more notable include:

• "In a rather amazing example of the taxpayers actually getting something for their money…"
• "A trove of free health information technology teaching materials for higher education has been opened…"
• "The Office of the National Coordinator for Health IT has publicly released teaching materials to help develop the nation's health IT work force..."

Second, a well-produced version of a recent talk of mine has been posted on YouTube by my colleagues in the Department of Biomedical Informatics at Ohio State University.

What is the Evidence Base for Informatics, Health IT, and Related Areas? Some Recent Analyses

The first part of 2011 has brought a number of publications, and subsequent discussion, about the "evidence base" for the efficacy of biomedical and health informatics interventions, including electronic health records. These publications and conversations come against a backdrop of a very poisoned political environment in the United States, where everything about healthcare, including informatics, has become unfortunately very politicized. In this posting, however, I will stick to the science.

The first high-profile study of the year was the on-line posting of the Archives of Internal Medicine paper by Romano and Stafford [1], which I discussed in an earlier posting. The official publication of the paper, as well as letters about it, will be published in May, 2011.

Probably the next most high-profile study was the publication of an update of a systematic review of studies of outcomes from health information technology interventions by Buntin and colleagues [2]. This was actually the second update of an original systematic review that was published in 2006 by Chaudhry and associates [3], the first update of which was published by Goldzweig and colleagues in 2009 [4].

Systematic reviews are comprehensive reviews of all research evidence on a given area or question [5]. When studies are homogeneous enough (e.g., all studies assessing the treatment of hypertension to reduce cardiovascular disease), a mathematical technique known as meta-analysis can be performed to combine results across studies to achieve larger a sample size and more statistical power. But most areas, certainly so in informatics, have research questions too heterogeneous to enable use of meta-analysis. Nonetheless, studies can be categorized to look at general questions asked, such as efficacy of decision support to reduce medical error or access to data in a more timely manner to reduce cost of care.

The three successive systematic reviews [2-4] using relatively similar methodology have summarized outcomes of studies of health information technology (HIT) over particular time periods:

• Chaudhry, 2006 – studies from 1995-2004 [3]
• Goldzweig, 2009 – studies from 2004-2007 [4]
• Buntin, 2011 – studies from 2007-2010 [2]

As with most systematic reviews, these captured a broad net of literature and reviewed it for quality of methodology and its results.

Chaudhry et al. identified 257 studies, with the most benefit shown for:

• Adherence to guideline-based care
• Enhanced surveillance and monitoring
• Decreased medical errors

An interesting caveat of the results that the authors noted was that 25% of the identified studies came from four institutions (Partners Healthcare, Veteran's Administration, Indiana University/Regenstrief Institute, and Vanderbilt University) and there were few studies of commercial systems, raising concerns about generalizability.

In their update, Goldzweig et al. found 179 new studies. They noted comparable results to the study of Chaudhry et al., but also found an increased number of studies of patient-focused applications that ran external to EHR, e.g., Web-based care management. They note a small increase in the number of studies of commercial, off-the-shelf systems, though 20% of studies still came from the four leading institutions. They also found there was still a paucity of cost-benefit analyses.

In the new systematic review, Buntin et al. identified 154 new studies with 278 individual outcome measures. While acknowledging wide divergence of study quality and methodologies, not to mention outcomes studied, they noted that 96 (62%) of studies had positive improvement in one or more aspects of care, with 142 (92%) showing positive or mixed positive-negative outcomes. They found that the studies used quantitative and qualitative approaches, with those using statistical hypothesis testing more likely to have positive outcomes. They slightly redefined “health IT leader” institutions, but noted that a large number (28) still came from these institutions, but did decreased somewhat to 18% of the studies. Somewhat reassuring  was that the “leader” studies did not differ in methods or results from the other studies.

Buntin et al. grouped the outcomes into seven categories, noting document improvement in all of them:

• Access to care
• Preventive care
• Care process
• Patient satisfaction
• Provider satisfaction
• Effectiveness of care
• Efficiency of care

Another bit of evidence from early 2011 was a review of all eHealth systematic reviews took exception to direction and quality of evidence [6]. The authors note that many studies of eHealth, including clinical applications (i.e., health IT), had poor methodology, raising concern over validity of the results. The results echo those of a systematic review I led about telemedicine studies several years ago [7]. One concern about this new review is that its methodology of being a review of reviews might magnify poor evidence. But someone needs to reconcile this review with the one of Buntin et al. [2].

It should be noted that another line of thought has been critical of the experimental approach to evaluation of health IT. Two recent commentaries note that these approaches cannot capture the whole picture of a health IT intervention, especially ones that occur in real-world implementations in complex settings, like states or even whole countries [8, 9]. I acknowledge these criticisms, though would argue back that we should not view these approaches as either-or. There is hopefully plenty of room for all types of disciplined evaluation of informatics, with clinical trials and similar experiments

References

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, Epub ahead of print.
2. Buntin, M., Burke, M., et al. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs, 30: 464-471.
3. Goldzweig, C., Towfigh, A., et al. (2009). Costs and benefits of health information technology: new trends from the literature. Health Affairs, 28: w282-w293.
4. Chaudhry, B., Wang, J., et al. (2006). Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144: 742-752.
5. Anonymous (2011). Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC, Institute of Medicine.
6. Black, A., Car, J., et al. (2011). The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Medicine, 8(1): e1000387.
7. Hersh, W., Hickam, D., et al. (2006). Diagnosis, access, and outcomes: update of a systematic review on telemedicine services. Journal of Telemedicine & Telecare, 12(Supp 2): 3-31.
8. Greenhalgh, T. and Russell, J. (2010). Why do evaluations of eHealth programs fail? An alternative set of guiding principles. PLoS Medicine, 7(11): e1000360.
9. Patrick, J. (2011). The validity of personal experiences in evaluating HIT. Applied Clinical Informatics, 1: 462-465.

Reflections at the End of Another Amazing Year for Informatics

Last year, in wrapping up the first year of the Informatics Professor blog, I marveled at how amazing the year of 2009 had been. I noted that the year started with both uncertainty and hope; the former fueled by the recession and the precarious financial state of Oregon Health & Science University (OHSU) due to that recession and the latter driven by the excitement of the election of President Barack Obama and (at least for me) the hope for real change. By the end of 2009, it was clear that profound change had indeed occurred, if not generally then at least in the biomedical and health informatics field.

The hope and change, of course, were driven by the HITECH program with the president's economic stimulus package. At the end of 2009, the path forward was clear: health information technology would be driven by the concept of "meaningful use," and the part nearest and dearest to my heart, education and training, would be driven by the ONC Workforce Development Program, which itself was driven by Section 3016 of the HITECH Act that I played a role in influencing.

I spent the latter days of 2009 and early part of 2010 writing proposals, in particular for the curriculum development program and the university-based training program. With the Funding Opportunity Announcements (FOAs) for these and other programs, such as Beacon, SHARP, and regional extension centers, released in December and due in January, many in the informatics field lamented that ONC stood for the "Office of No Christmas." I spent a good part of my winter break last year working on these proposals. The only enjoyable aspect of the process was that they allowed us to envision how we could implement the educational programs we always dreamed of if we ever had the money, which now it looked like we did.

The most harrowing part of the year was the time between the submission of the proposals and receiving word about funding. As well-positioned as we were to receive these competitively awarded proposals, there was an undercurrent of fear that perhaps we forgot to address some required aspect of the program or that some reviewer felt we had taken the wrong approach. In all honesty, it would have been quite an embarrassment to not be selected for funding, since OHSU's program laid the groundwork for some of the thinking that had emerged surrounding health IT workforce development.

All the agony came to an end on Friday, April 2nd, when I awoke in the morning to find out that both OHSU proposals had been funded. For the curriculum development project, we were not only funded as one of the five curriculum development centers, but also chosen as the lead National Training and Dissemination Center (NTDC). For the university-based training program, we were one of nine programs selected for funding tuition assistance in our graduate program. A common quip in academia is that the downside to getting grants funded is that you then have to do the work. However, this was literally a dream come true. Between both grants, we were funded for $5.8 million to do what we always envisioned we could do if we had the funding. While the short-term emphasis of the funding (due to their being stimulus funds) required us to make some decisions we might otherwise not make, it was still a great position in which to be.

Also on the second to last day of 2009, the preliminary meaningful use rules were released. These were followed by a 60-day comment period, modification of the rules, and the release of the final rules on July 13th. I happened to be in a hotel room in Singapore (10 pm local time, 10 am Eastern time) when listening to their unveiling. While everyone had qualms with this criteria or that criteria, I believe that the majority of people were content with the approach to meaningful use taken by ONC.

With our own projects, we hit the ground running. Out of the gate, the curriculum development project required the most work up front. After a two and a half day workshop in Washington, DC the second week of the grant, we began our long quest that would result in the first version of the curriculum being developed and handed off to the community colleges by the end of October. Being the NTDC, OHSU also had to organize a training event for community college faculty in August and launch a Web site for dissemination of the materials around that time, both of which we did. We even added an aspect to the project of creating an educational version of the VA VistA electronic health record system.

The university-based training grant project was a little slower to get started, but not by much. With funding for 135 Graduate Certificate and 13 master's degree students over three years, our plan was to use the funding mainly as a form of tuition assistance for new students entering the field. We started providing support for students in the summer academic quarter and really ramped up in the fall. The main regret is that we have received two to three times as many qualified applicants as we having funding to accept. A decent proportion of those individuals have enrolled as self-funded students.

While a good proportion of my year was spent around these ONC initiatives, there were other achievements as well. Due to ONC and other funding, the Department of Medical Informatics & Clinical Epidemiology catapulted to second among the 25 departments at OHSU in external funding. We have many other initiatives in comparative effectiveness research, bioinformatics, and related areas. The big challenge for the department in 2011 and beyond is how to consolidate and build upon the success of the stimulus-era funding. I am confident we will find ways to do this, as the need for our disciplines to advance healthcare, personal health, and biomedical research will not diminish even as the federal budget tightens.

The coming year will also be an interesting one for the informatics world. How many eligible professionals and eligible hospitals will achieve meaningful use? What unforeseen bumps in the road will emerge? How will healthcare reform impact the use of health information technology? What will happen to healthcare reform itself? One thing is certain: we will live through exciting times!

I have now been writing this blog for almost two years. I have been pleased to have this type of forum to share my views on various aspects of my work. I am also pleased that others have noticed, not only the 129 people who follow the blog, but also winning awards like being on the list for the 2010 Top Math & Science Professor Blogs Award.

I plan to keep running the blog pretty much like I have been, with a fewer number of more substantive posts than the stream of consciousness approach used by many other blogs. I do hope to branch out a little bit more this coming year beyond workforce and education, as I occasionally did this year.

The Emergence of the Informatics Practitioner

There have been many changes in the biomedical and health informatics field since its inception in the 1960s and even since my entry into it in the late 1980s. Some of these changes have been due to changes in technology, e.g., from the teletype and punch card computers of the 1960s to the advent of personal computers in the 1980s to the current era of high-powered computers and smaller devices connected to the ubiquitous global Internet. Other changes have come from scientific maturation of the field, such as a better understanding of the proper role for computerized clinical decision support and the emergence of enabling technologies from genomics and related areas.

Another area where profound change has occurred is in the professional work of informatics. When the field started to develop in the 1960s, and even when I assumed my first faculty position in the early 1990s, most who worked in informatics thought of themselves as researchers. The primary work of academic informatics departments was research and development. Most who were trained in the field obtained fellowships and/or advanced degrees. While many academic informaticians took on some operational roles in their institutions, the focus of that work was mainly implementing novel cutting-edge technology. Research, meanwhile, focused on developing new systems, models, and algorithms to meet what we thought were the needs of clinicians, scientists, consumers, and others.

Over the last decade, many changes have occurred. One of the biggest of these changes is the emergence of the informatics practitioner (or professional). Now that the use of information technology (IT) has become a routine (if mission-critical) activity of healthcare and other health-related organizations, there is growing recognition of the need for skilled individuals who understand both the technology and its use in a given underlying health domain. These professionals need not be highly technical, though they must be facile with IT and, perhaps more importantly, savvy with the management and analysis of information.

The jobs of informatics practitioners are diverse. These individuals may undertake tasks such as extracting data from "dirty" data sources (such as clinical records) for quality measurement and improvement. They may serve as champions or implementers for information systems to meet the needs of these organizations. They might maintain large bioinformatics databases or use them to analyze the data of researchers with whom they collaborate. At the top end of organizations, the chief information officer (CIO) or chief medical information officer (CMIO) increasingly provide key strategic leadership around information systems and use of the data within them.

A number of academic informatics faculty who grew up in the earlier era have not recognized the change. I have to admit that I realized it earlier than most mainly because of the demands from students in our nascent educational programs asking to learn more about how to implement systems than do research. Many academic leaders still have difficulty discerning between the differences in training researchers and practitioners.

I do not, however, see the emergence of informatics practitioners or educational programs designed for them as being at odds with the research mission of academic informatics departments. In fact, I view it as complementary. All mature fields, certainly those in the health professions such as a Department of Medicine, have both practitioners as well as researchers and educators. The researchers discover new knowledge and techniques while the educators disseminate it to the practitioners. All professions have academic departments whose missions entail both research and education. I see this starting to occur in informatics programs around the world and is certainly the modus operandi of our department at Oregon Health & Science University (OHSU).

With the large IT investments being made in healthcare, public health, and research organizations, along with the need and desire for baby boomers to manage their increasing use of healthcare, I see a bright future for informatics practitioners. The informatician will rightfully take his or her place on the larger healthcare team, delivering needed expertise on the integration and coordination of information for optimizing people's health.

The Informatics Outlook for Physicians

In looking over the topics I have addressed in the year and a half of this blog, I have tried to convey biomedical and health informatics as a broad field with many roles and opportunities for people from a wide variety of professional backgrounds. One group that I have not addressed explicitly is physicians.

I admittedly have a kinship for physicians in the informatics field. After all, I am a physician by training, and even though I know longer actively care for patients, my training and early career experience provide a perspective that informs my understanding of the role of physicians in informatics.

Overall, the opportunities for physicians in informatics are substantial and growing. While many early informatics roles for physicians focused on research and development, the real growth opportunities are now for those seeking to be informatics practitioners. These practitioners play a variety of roles not only in planning and implementing systems, but deriving value from the information within them.

An ever increasing number of healthcare organizations have recognized the importance of physician informatics leadership, manifested most frequently in positions that go by the name of Chief Medical Information Officer or Chief Medical Informatics Officer (both of which conveniently are represented by the acronym CMIO). While the CMIO position is probably now the most visible physician role in informatics, it is hardly the only one. Physicians also play other roles in healthcare organizations as well as other entities, such as vendor, consulting, government, and research organizations.

The OHSU biomedical informatics graduate program has always had a strong representation from physicians, who comprise about 50% of our enrollment. They are therefore not the only demographic of student in the program, as we also have students from other healthcare professionals (e.g., nurses, pharmacists, lab/radiology technicians, health information managers) as well as from outside the health professions (e.g., information technology, computer science, and even further afield from law, biology, business, and others). Furthermore, the professional diversity of our program has always, in my mind, been one of the program's assets, even though trying to teach informatics simultaneously to a physician, nurse, computer scientist, and businessperson can be a challenge!

But it nonetheless has been gratifying to see many physicians go on to assume roles and leadership in the field. The diverse roles that physicians who enter the field take exemplifies the expansion of these roles.

There are a number of issues ahead for physicians contemplating careers in informatics to ponder. One concerns training. How much should they seek? Should they get it at all? If they do, in what kinds of programs should they train? I honestly cannot give an unequivocal answer. There are many physicians who move into informatics roles without any formal training. However, I do believe over time that formal training will be a requisite for informatics jobs. If nothing else, one's competitors for those jobs will have such training.

As for how much training, that is also an uncertainty. There is a growing recognized knowledge base for the informatics field. There is also recognition of an increasing number of best practices. Physician-informaticians might not need to understand all the technical details of the systems with which they work, but they must have the big picture both of the technology and how it fits into their environment.

Another issue on the horizon for physicians is certification, in particular the proposed clinical informatics subspecialty. This subspecialty will be available to physicians in many, perhaps all, specialties (e.g., internal medicine, pediatrics, family medicine, surgery, etc.). There are still many unknowns about this process, such as how will other informatics experience and training besides formal on-site fellowship training be viewed and how physicians without board certification might be able to take part. Nonetheless, certification is important in healthcare professions, and certification in informatics will lead to more professional recognition of the field.

I believe it is safe to conclude here are tremendous opportunities for physicians to be innovators and leaders in the proper and most effective use of information technology IT) not only in healthcare, but also personal health, public health, and research.

Despite the uncertainty about some of the details, the outlook for physicians in informatics is bright, even after the initial wave of EHR adoption is complete (as addressed in a previous blog entry). The need for expertise in health IT implementation will only increase, especially as we see more coordination and quality measurement of care delivery.

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

A couple new articles in medical journals give some added perspective for the direction of biomedical informatics and its role in healthcare. The articles are physician-oriented but could easily be applied to other healthcare professionals or for that matter patients, consumers, and researchers.

The first was published on-line ahead of print in Academic Medicine and authored by Bill Stead of Vanderbilt University and four colleagues. The main thesis of this paper is that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains." The authors note that the numbers of facts per clinical decision will increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.). While I would argue whether genomics has yet had much impact in clinical medicine, I do acknowledge that just the complexity of our clinical knowledge of diseases, tests, and treatments is already overwhelming what Stead and colleagues call the "human cognitive capacity." When you factor in the social and economic complexity of our healthcare system, you do not even need genomics to make it exceedingly complicated, even though genomics is likely to make it more so.

These authors also note the consensus developing around the core competencies for the biomedical informatics field being developed by the AMIA Academic Forum. One particularly valuable exercise of this paper is to map the key competencies to the six core competencies for future health professionals first enumerated by the Accreditation Council for Graduate Medical Education (ACGME).

The authors envision a central role for academic health centers (AHCs), recommending advancement in four areas (to quote):

• Create academic units in biomedical informatics
• Adapt the IT infrastructure of AHCs into testing laboratories
• Introduce medical educators to biomedical informatics sufficiently for them to model its use
• Retrain faculty in AHCs to lead the transformation to health care based on a new systems approach enabled by biomedical informatics

Indeed, these activities could be an instance of the Health Innovation Zones that the Association of American Medical Colleges calls for AHCs to become.

The authors state that "embracing this collective and informatics-enhanced future of medicine will provide opportunities to advance education, patient care, and biomedical science."

The second paper is a commentary by Ted Shortliffe of AMIA in JAMA. This piece appears in the annual special issue of JAMA to devoted to medical education. As such, it focuses on medical education and has a central thesis that the focus of medical practice is as much information as it is patients. Yet while medical education goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort at obtaining, using, and analyzing information.

Shortliffe notes that biomedical informatics should be a discipline fundamental to medical education, focusing on both its practical application and core fundamental concepts. He points to a number of examples of where medical practice could benefit from informatics. Few students, he note, are skilled at searching. While anyone in the world can do a Google search, most medical students are not able to skillfully use the myriad of search systems available, from PubMed to the clinically oriented genomics databases. Likewise, few students have mastery of using an electronic health record, let alone make critical secondary use of its data for quality improvement, patient empowerment, or clinical research. I suspect that a paucity of medical students understand the full ramifications of privacy and security, health information exchange, or other informatics topics that will impact their practices in a large way in the coming decades.

One detractor of teaching more informatics to medical students at OHSU used to argue that today's students have no need for such instruction, since they are digital natives, proficient in email, social networking applications, and smart phone usage. Yet these technologies are not informatics, which Shortliffe pulls from the AMIA core competencies definition as "the interdisciplinary, scientific field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making motivated by efforts to improve human health."

I hope these articles are widely read and acted upon by healthcare leaders, educators, and forward-looking practitioners.

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

A question I am asked from time to time is whether there will be a need for informaticians once we are "done" implementing electronic health records (EHRs). My reply is that implementing EHRs is only a beginning, and actually not the most interesting part. Much more important is what we do with those EHRs and other information systems after they are implemented.

Once EHRs are implemented, there will still be all sorts of "meaningful" things that need to be done with them, and I am not just talking about the meaningful use guidelines, though those will keep us busy well past the middle of this decade. (Even the Office of the National Coordinator for Health IT [ONC] believes it unlikely that most eligible professionals and hospitals will achieve Stage 3 meaningful use before 2018-2019.)

But I only see healthcare becoming more data-driven in the future, with increasing emphasis on managing information to provide safe and less costly care. Activities such as quality measurement and improvement, improving efficiency, dealing with new types of information, and continued advances in information technology (IT) are likely to keep us busy for a long time to come.

One insight to these future needs comes from a new article by Bill Stead and colleagues (Academic Medicine, 2010, Epub ahead of print). It is unfortunate that this article is published in a journal that requires an individual or institutional subscription to access it, because it presents a clear picture that the complexity of information required to practice medicine is increasing and that clinicians - and the educators who train them - must learn how to function in the increasingly "information-rich" healthcare environment.

This article also lists a number of key competencies in informatics for physicians, organizing them within the framework Accreditation Council for Graduate Medical Education (ACGME) core competencies for physicians. The article also recommends that informatics become a foundational science for healthcare, advocating development of academic units involved in academic and operational activities, using the IT infrastructure of academic health centers as testing laboratories, and retraining faculty to lead the transformation of healthcare through the use of informatics.

There are many other reasons why informatics will not cease to be important once there are EHRs on every desk in healthcare. As us baby boomers age and develop more health problems, we will likely want to manage our healthcare the way we manage many other things in life (e.g., banking, air travel, buying certain things such as books, etc.), which is on-line. We also know that there is still plenty of room for improvement with existing EHRs. Data entry is too time-consuming, poor interfaces can hide critical data, and we still need much smoother interoperability, especially of data. The ONC SHARP program acknowledges the need for continued research in the four areas it is funding: architecture, privacy and security, secondary use of data, and cognitive-centered computing.

In essence, the implementation of EHRs enables a whole host of other activities that will allow improvement of health, healthcare, public health, and biomedical research. As such, there will only be increased demand for informaticians to perform and lead these activities.

Informatics is a Field of Global Truths

As all of my friends on Facebook know, I recently spent an enjoyable two weeks in Asia, with stops in Hong Kong, Singapore, and Bangkok. Certainly one of the things I enjoy most about my work is getting to interact with colleagues in the field from all over the world.

One thing I have definitely learned in my countless interactions with friends, colleagues, and others in Europe, South America, Asia, Africa, and elsewhere is that the principles of informatics apply no matter where you are on the planet. There are indeed global truths in the informatics field, just as there are in medicine, i.e., while different diseases occur with different frequencies and somewhat different manifestations around the globe, the same basic pathologies that afflict the human organism do so no matter where the human is located. Whether it is infectious diseases or chronic diseases, relatively similar approaches to diagnosing and treating disease apply universally.

I believe that the same notion applies in informatics. That is, the factors that motivate and govern informatics in the United States do the same elsewhere, i.e., the use of information to improve human health, healthcare, public health, and biomedical research. This does not mean that some of the issues manifest themselves in diverse ways in different settings. But principles like the need to understand the clinical setting and its workflows as well as to provide value to the full spectrum of "users" from clinicians and citizens to institutional leaders and ministries of health apply universally.

I have also come to learn in this journey that there is a global need to build human capacity in informatics. Indeed, I had the opportunity to share thoughts and a framework for developing it in a paper published in the current issue of the journal Health Affairs, which is devoted to eHealth in the developing world. My co-authors include Dr. Alvaro Margolis from Uruguay and Drs. Fernan Quiros and Paula Otero from Argentina. Other papers in the issue focus on other issues and challenges in this area, such as standards and interoperability, use of mobile health (mHealth) technologies, and policy development. As most people who work in this area know, there has been an explosion in the growth of mobile phone technology and its use to truly benefit these developing economies. A press release from the American Medical Informatics Association also summarizes the papers.

On February 16th, I will be in Washington, DC participating in a press event about the papers in this issue of Health Affairs. I intend to make the above points in the few minutes that I have to talk.

The notion of global truths in informatics was clearly visible on my recent trip. My first stop was in Hong Kong to lead a two-day seminar on health informatics for allied health professionals in the Hong Kong Hospital Authority. The Hospital Authority is undertaking an impressive comprehensive national program to develop a universal electronic health record (EHR) for all public hospitals. This system will also facilitate health information exchange (HIE) from private hospitals. One of the main reasons for the project's success to date has been the leadership of Dr. NT Cheung, who has paid meticulous attention to both the needs of all stakeholders of the system as well as the most appropriate technologies to be implemented. He has also assembled a well-trained team (some of whom I have also trained in the 10x10 course!). We (including those of us in the United States) can learn plenty about the right way to do informatics in this effort.

My next stop was Singapore, where I have been running an offering of the 10x10 course with my colleague Dr. KC Lun of Gateway Consulting. Although the course has attracted a regional audience, a large number of participants have come from the Singapore Ministry of Health Holdings and local healthcare institutions. There are many robust informatics projects being undertaken in Singapore, including a national EHR with HIE from various hospitals.

My final stop on the trip was Bangkok, Thailand, a country with a rich tradition of a strong healthcare system. One event in Bangkok was the opportunity to give a talk about informatics to the Dean and the clinical department chairs of the Ramathibodi Hospital Faculty of Medicine of Mahidol University. Being a department chair in a medical school myself, I had a natural kinship with this group, and enjoyed in engaging them in a well-informed conversation.

I also attended in Bangkok the Prince Mahidol Award Conference, which is an annual conference devoted to global health issues. The theme of this year's conference was Global Health Information Systems and how they can improve individual health, better inform health leaders, and improve the delivery of healthcare and public health. I gave a presentation on a panel devoted to the human resources capacity required to achieve optimal use of such information systems. The conference also adopted a Call to Action that, among other things, called for investments in building capacity.

I look forward to my continued work with colleagues around the world to build the capacity that allows informatics to play its role in improving health, healthcare, public health, and biomedical research.

Academia = Education AND Research

The American Medical Informatics Association (AMIA) Annual Symposium is clearly the best informatics meeting of the year. It is rigorously academic, so the quality is top-notch, but not too much, so you can glean plenty of practical information as well.

The AMIA symposium is also an opportunity for us because we can showcase our department. As always, our faculty and students will pepper the program with great papers, panels, and posters. In addition, the annual OHSU banquet is a gratifying display of the energy and passion of our program, not to mention quite fun. I look forward to this year's meeting in San Francisco later this month.

This meeting always give me a chance to reflect on the importance of a comprehensive academic program that values both education and research. A vibrant graduate-level program cannot thrive without both. Being at the cutting edge of research allows faculty to be the knowledge and thought leaders in their respective areas.

This was borne out a couple years ago when we hosted a focus group that assembled a number of what we call "local distance" students, which are students who live in the Portland area but prefer to enroll in our on-line program. We wanted to know why they preferred that instead of coming "up the hill" to the OHSU campus. The answers were obvious in retrospect: they appreciate the convenience of being able to carry out their studies at their preferred hours (usually evenings and weekends) and they did not want to deal with the hassle of driving to and parking on our campus (which everyone knows can be a pain, at least during regular working hours).

There was, however, another interesting finding that came from the focus group. These students told us they were drawn to our program not only because of its local connection, but also because they valued the faculty and their leadership roles in the field, especially their research. Even though they were unlikely to become researchers themselves, or for some to even do research, they believed it was important to obtain their education in a department that was known for being a leader in research as well.

As always, I look forward to catching up with students, alumni, and old friends at the AMIA meeting.

What Level of Training Is Needed for Health IT and Clinical Informatics Jobs?

There will likely be a large number of jobs that result from the funding in the American Recovery and Reinvestment Act (ARRA, aka the stimulus bill) of 2009 providing incentives for electronic health record (EHR) adoption. Dr. Charles Friedman of the Office of the National Coordinator for Health IT (ONC) recently estimated that 60,000 people will be required for these jobs (PHIN 2009 Meeting Town Hall, September 2, 2009). ONC also recently posted on its Web site a set of job roles and competencies for this massive scaling up of EHR use that was developed in a workshop in August.

One question that arises is, who will provide all this education and training? A number of people have advocated that it be carried out by community colleges. A recent article in Healthcare IT News interviewed two people, a health insurance company executive and a president of a community college association, who advocated for community colleges to play that role.

In a rebuttal commentary, however, I replied that I was not so sure. There is no doubt that plenty of jobs in health IT will be for those educated in community colleges, such as the "informatics technicians" noted in a recent CNN posting about "emerging jobs poised for growth." But this is in distinction to the emerging clinical informatics role, which requires a combination of understanding the clinical environment and its workflows, ability to use advanced information analysis (more so than IT or computer science skills), and a myriad of business and soft skills. As the director of an informatics graduate program, I acknowledge my bias, but I advocated in my commentary that these programs, slightly re-orienting and focusing their curricula, may be better suited for training up this workforce. Since the proposed training must necessarily be short-term, I noted in my commentary that we are re-configuring our Graduate Certificate program into a 6-month program when pursued as a full-time student.

One line of evidence supporting my view comes from the Health IT Compensation Survey (Vendome, 2009). This year's survey features a wealth of data that goes way beyond compensation, and provides an interesting synopsis of the job functions and educational backgrounds of a wide variety of people who work in the industry. They segment those they survey into job setting (i.e., hospital, company, etc.), and across every segment, they subdivide people into leadership, clinical, and non-clinical positions.

Those in hospitals make up the largest segment in the survey, so I will focus on them. Among the leaders, 18% have doctoral or professional degrees, 48% have master's degrees, and all but 4% of the rest have bachelor's degrees. They subdivide the clinical and non-clinical professionals into "high authority" and "low authority." The breakdown of degrees within these groups is:

• Clinical/High Authority: 34% have doctoral or professional degrees, 29% have master's degrees, and 30% have bachelor's degrees
• Clinical/Low Authority: 20% have doctoral or professional degrees, 31% have master's degrees, and 35% have bachelor's degrees
• Non-Clinical/High Authority: 1% have doctoral or professional degrees, 36% have master's degrees, and 38% have bachelor's degrees
• Non-Clinical/Low Authority: 1% have doctoral or professional degrees, 24% have master's degrees, and 51% have bachelor's degrees

Clearly a majority of health IT professionals, especially those with clinical roles, have at least a bachelor's degree, and many have more. This is not surprising, as effective training for health IT requires expertise in the clinical environment, IT and information skills, and the ability to work with people in organizations. As I note in my commentary, that is a tall order for any educational program, let alone a two-year associate degree.

I do realize that community colleges play a strong role in rapidly adapting to skills needs in communities, and that many of their students are those who have bachelor's or even graduate degrees and return to attain new skills. And there is no question that some of the jobs in health IT will require the kinds of skills that community colleges already teach, such as those in pure IT. I acknowledge that the person hired to harden a server to prevent its security from being compromised probably does not need courses in change management. But many others who work in health IT do!

The reality is that few community colleges have expertise on their faculty in clinical informatics, which is not the mere addition of computer science, health information management, and health care courses as many seem to think. Informatics is what arises at the unique intersection of those areas, and the expertise for teaching it currently resides mostly in graduate-level informatics programs.

A Tale of Two Professions: Biomedical/Health Informatics and Health Information Management

The OHSU Biomedical and Health Informatics Program recently had a new track in its Graduate Certificate accredited by the Commission on the Accreditation of Health Informatics and Information Management (CAHIIM). This culminated a several-year effort to establish a track within the program devoted to health information management (HIM). It will allow those who complete the track to sit for the Registered Health Information Administration (RHIA) credential.

While we are very proud of this accomplishment, and our desire to integrate informatics and HIM, it has probably added more confusion to a field that is already bereft with misunderstandings about its name, scope, and many other things. Nonetheless, I believe that the positives vastly outweigh the negatives. Both fields started in a very different place, but are increasingly converging toward the same intellectual content and professional work. Both fields need to adapt if they wish to meet the agenda for health information technology in the 21st century health care system.

The informatics field began as an academic research discipline, housed mainly in medical schools. Most working in the field had doctoral degrees, either an MD or PhD, and sometimes both. Much of the early work was funded by federal research grants. The HIM field, on the other hand, has always been one of the "allied health" professions. Its education has been at the lower end of the higher education spectrum, with a great deal of programs in community colleges.

In recent years, however, the two fields have moved much closer. Informatics has had to adapt as its applications, mostly notably electronic health records, have become "mainstream," with the concomitant growing need for professionals who can lead and support their adoption in operational health care settings.

HIM has had to adapt as well. The skills associated with managing folders of paper and record rooms have become obsolete, requiring updating to focus on the other important aspects of HIM practice, such as compliance, legal issues, and use of coded data.

This naturally gives rise to the question of where one discipline ends and the other one begins. Or, in a more practical question being asked by students considering study at OHSU, who should pursue the HIM track and who should pursue the regular clinical informatics track?

This is unfortunately not a simple question to answer, which I am sure leads to some frustration among those considering education and/or careers in a program such as ours. Part of decision must rest on career goals and professional identity. Even though HIM work is expanding more broadly into areas historically covered by informatics, the reality is that most HIM professionals still focus somewhat narrowly on the health record. This is not a bad thing, as there are many important tasks for the electronic health record (EHR), and HIM professionals are highly skilled in leading those efforts. Certainly someone who wants their career to focus on classical HIM tasks in an electronic world ought to pursue the HIM track. Likewise, if one wishes to identify as an HIM professional, this track is essential.

For those with clinical and/or information technology (IT) backgrounds who want to pursue what is increasingly known as "clinical informatics," my recommendation would be to pursue the conventional informatics track. There is still plenty of opportunity to focus on EHRs, but general informatics also allows their broader application. Our program has seen a number of HIM professionals enroll and graduate in an attempt to broaden the breadth of their expertise. Of course, as informatics moves to add credentialing to its professionals, we may see a blurring or even a merging of credentials from the two fields.

One positive consequence of our new HIM track is that it provides expanded coursework in our larger informatics program. Indeed, many students in the conventional track have found these new HIM courses interesting and worthwhile. Another important value of having the track is letting the community know that our informatics program is "HIM-friendly."

Going forward, I see continued convergence of informatics and HIM. HIM shares the attributes to which I have ascribed in other writings to informatics, namely that we are focused more on information than technology, and that our work's main goal is to improve health, health care, and biomedical research.

Informatics: A Field and Profession Coming Into its Own

If there is one gratifying aspect about the informatics field in recent years, it has been the field's self-identification. The role of informatics, distinct from information technology (IT) as well as other health care professions, has been established. This is important for any discipline, especially for those who are professionals in the emerging field and those studying to enter it.

I recently had the opportunity to expound on this in a couple interviews. In both of them, I appreciated that the interviewers published essentially unedited transcripts of their questions and my answers. Sometimes it is appropriate for writers to try to summarize an interview, but often they end up over-simplifying or getting things wrong. These interviews, on the other hand, are both a nice stream of consciousness.

The first interview is an audio interview on the XM Radio show, ReadyMD. To listen to the interview, you need to follow this link:
http://www.reachmd.com/xmsegment.aspx?sid=4565
(When you get to the page, you have the option to play the interview on the page or to download the Podcast [MP3] file. If you choose the former, you need to create a free account on their Web site to access the interview. The latter allows you to play or even download and save the audio file.)

The second interview is on the famous (infamous?) blog, Mr. HISTalk, which is an authoritative site for both news and gossip in health IT:
http://histalk2.com/2009/08/05/histalk-interviews-william-hersh-md/
This interview is a text transcript, but for the most part is a verbatim stream of consciousness between the interviewer and myself. We cover a number of topics, not only workforce and education, but also clinical data issues and the stimulus package. (And no, I cannot divulge the identity of Mr. HISTalk. Even if I knew more than his first name!)

Of course, not all people who write about informatics field get it right. (Though is the old showbiz adage true, that any publicity is good publicity?) In any case, a recent posting on the CNN CareerBuilder.com Web site describes "seven emerging jobs poised for growth," one of which is a "health informatics technician":
http://www.cnn.com/2009/LIVING/worklife/08/04/cb.7.emerging.jobs/

According to the site, there is huge growth opportunity as health care facilities transition to electronic health records. Sounds great, until they list the salary: $31,208! I assume this is an annual salary, but I am flabbergasted, since the salaries in this field are in reality so substantially higher, even for entry-level jobs. The only people in the field who make that low of a salary are the PhD students on stipends from our NLM training grant! Even the postdocs on the training grant make more, and every other person I know in the field makes more than this, some a whole lot more.

If you look at the Healthcare Informatics 2009 Compensation Survey, you see that those in clinical positions make median salaries of $78,000 ("low authority") to $111,000 ("low authority"). Those in non-clinical positions make median salaries of $80,000 ("low authority") to $92,000 ("low authority"). Senior executives have mean salaries of $150,000. (All of these data are for those working in hospitals, but they are comparable for others who work in other health care settings as well as for companies.) Other data show Chief Medical Information Officers make $150,000-$300,000 (depending on their clinical background).

So this is a professional that has found its identity and the salary opportunities are pretty decent!

Informatics Education: A Final Common Pathway

As readers of this blog know from my other writings, the field of biomedical and health informatics is heterogeneous and diverse. The types of jobs performed by informaticians range from the highly technical to those that are more people and organizational in nature. The entire spectrum is vitally important. A unifying common element of these jobs is that they are somehow related to the use of information, often aided by technology, to improve individual health, health care, public health, and biomedical research.

I am also delighted to report that US News & World Report still considers informatics be one of its "ahead of the curve" careers. There is a Web page devoted to it, where I recently posted a comment.

• http://www.usnews.com/articles/business/best-careers/2008/12/11/ahead-of-the-curve-health-informatics-specialist-2009.html
• http://www.usnews.com/articles/business/best-careers/2008/12/11/ahead-of-the-curve-health-informatics-specialist-2009/comments/

As any director of an informatics education program can tell you, teaching informatics is a challenge. You have physicians, other health care professionals, computer scientists, health information managers, and many others sitting (virtually and in classrooms) alongside each other. Furthermore, many are adult learners, already having completed their primary education and often having substantial work experience.

Of course, educating such a diverse group can also be a real joy. Most of these individuals are very smart and highly motivated. I learn a great deal from them, and they require me to keep a step ahead in my knowledge.

Because of all this, I think of informatics education as a "final common pathway" for many individuals who bring diverse backgrounds, interests, and talents to the field. Such individuals will be uniquely qualified to develop, implement, and lead health IT, especially in the coming years.

It is hard to fathom this education not taking place at the graduate level. I recognize there are growing numbers of community college and undergraduate programs in informatics, but I tend to view these as one of the many pathways leading to that final common one. Most of the associate and baccalaureate programs in informatics are really IT programs with some health-related content added. This does not mean they cannot be of value to individuals or make contributions in health care settings, but such individuals are not likely to "practice" informatics as we normally define it.

I suspect that the informatics profession and its education will become more standardized in the coming years, especially as we see certification of individuals, with the commensurate accreditation of programs.

Just What the President Ordered

Readers of this blog may be interested in a new press release today from OHSU. It can also be viewed at:
http://www.ohsu.edu/xd/about/news_events/news/justwhatthepresidentordered.cfm

June 30, 2009

Contact: Tim Kringen, 503 494-8231; kringent@ohsu.edu

JUST WHAT THE PRESIDENT ORDERED
OHSU biomedical informatics hires interns, trainees, and college faculty with federal stimulus funds

PORTLAND, Ore. – Oregon Health & Science University has received funding from the American Recovery and Reinvestment Act, and will do exactly what President Obama ordered: hire trainees and summer interns for its biomedical informatics training program. The new hires include undergraduate and graduate students as well as community college faculty.

The federal economic stimulus funding was received by the Department of Medical Informatics & Clinical Epidemiology (DMICE) in OHSU’s School of Medicine. “This will do exactly what the President intended: provide jobs and help build expertise in health information technology,” said William Hersh, M.D., professor and chairman of DMICE. “This will be good for patients, who will see improvements in quality of care through the use of information technology. It will also be good for Oregon’s economy, as our state is positioned to be an industry leader in health IT due to the presence of established and emerging companies and the strength of the biomedical informatics program at OHSU. We’re very excited about this opportunity.”

Summer interns have already started arriving on campus and will work on a variety of projects under the mentorship of OHSU biomedical informatics faculty. A total of thirteen students are participating in the internship program, and come from a variety of colleges and universities, including the University of Oregon, Oregon State University, Portland State University, Scripps College, and Northwestern University.

Brian Bakke is a sophomore at Portland State (PSU) studying computer science. “I’m interested in ways that technology can make health care more accessible for patients and simpler to understand.” Bakke is in the “3+2” joint biomedical informatics program between PSU and OHSU that allows students to receive both a B.A. in Computer Science and an M.S. in Biomedical Informatics during a coordinated, five-year course of study. “I think informatics is poised to make significant contributions to improving the American health care system in the coming years and I hope to be a part of that.”

Peter Ryabinin is a Portland native currently studying mathematics at the University of British Columbia in Vancouver, Canada. Like many of his fellow summer interns at DMICE, he is interested in getting some work experience and finding out more about the field of biomedical informatics. “I enjoy applying mathematical ideas to the real world,” he said. “I think informatics is a way to do that and I want to see if it’s the right fit for me.”

All who participate in the program will take away valuable knowledge and skills they can pursue further study in the field (college interns), curriculum development in community colleges (faculty), and employment in the field (graduate student fellowships).

John Blackwood is a faculty member at Umpqua Community College in Roseburg, Oregon. He teaches in the Computer Information Systems degree program, a two-year sequence of classes designed to prepare students for employment as an entry-level network administrator, computer support person, Web designer, or computer programmer. “Informatics, at the associate degree level, is a relatively new employment opportunity and I want to educate myself so that I can help prepare my students to take advantage of more career options.” Blackwood and fellow DMICE summer hire Michael Talbert of Portland Community College are developing the curriculum for an associates degree in health informatics that they hope will be adopted by the state and available at all community colleges in Oregon. “The jobs are there. We just need to ensure that our students have the right mix of skills to be attractive to employers.”

The final group of trainees will begin arriving in the late summer and early fall. These will be graduate students pursuing Ph.D. degrees as well as postdoctoral fellows (with an M.D. or Ph.D.) who will be seeking advanced education in the field that will allow them to develop careers in this growing field. They will pursue a course of study that will culminate in a research project under the mentorship of an OHSU faculty member.

The stimulus funding comes to OHSU from the National Library of Medicine, which is part of the National Institutes of Health, the government agency devoted to biomedical research and training. OHSU will receive $184,810 for the summer internship program and $1.15 million for the fellowships. Further health information technology will be forthcoming in the future from other initiatives in the stimulus package as well as legislation sponsored by Oregon Congressman David Wu.

About OHSU

Oregon Health & Science University is the state's only health and research university, and Oregon's only academic health center. OHSU is Portland's largest employer and the fourth largest in Oregon (excluding government). OHSU's size contributes to its ability to provide many services and community support activities not found anywhere else in the state. It serves patients from every corner of the state, and is a conduit for learning for more than 3,400 students and trainees. OHSU is the source of more than 200 community outreach programs that bring health and education services to every county in the state.

Informatics Defined, Explained

I have had the opportunity lately to further define and explain the field of biomedical and health informatics. I make this entry to provide pointers to them.

First, I just published a paper in BMC Medical Informatics & Decision Making that defines the major terminology of the field. This paper had its genesis during the frenzy around the time that the ARRA economic stimulus bill was being crafted. It became apparent to me that many on Capitol Hill did not know the terminology of the informatics field well, so I drafted a document that defined the major terms. I received some great feedback on the document, and subsequently submitted it to BMC Medical Informatics & Decision Making. It has now been peer-reviewed and accepted for publication. It can be found at:
http://www.biomedcentral.com/1472-6947/9/24/

I tagged the paper as a "Debate" paper, recognizing that not everyone will agree with my terminology. This will hopefully generate some debate such that some amount of consensus can be reached.

By the way, the publishing process of BMC is fascinating. You can read the comments of the peer reviewers (four highly prominent colleagues!) and my replies to them.

I have also updated and slightly renamed my What is Biomedical and Health Informatics? Web page, which gives an overview of the field via links and a voice-over-Powerpoint lecture. It can be accessed at:
http://www.billhersh.info/whatis/

Finally, I have carried out an overhaul of my web page, which needed a good cleaning! It is still at:
http://www.billhersh.info/

Learning about Informatics and Health IT at OHSU

The interest in health IT and biomedical informatics continues to grow, fueled no doubt by federal policy efforts and the economic stimulus plan. One result is that many people have inquired to me about opportunities to learn more about the biomedical informatics field at OHSU. To that end, I am going to describe the options in this posting. If you have further questions, feel free to contact me individually.

OHSU's programs are open to people of all career backgrounds. Our programs have served a wide diversity of people over the years, including those with backgrounds in health care (e.g., medicine, nursing, hospital administration, etc.), IT (e.g., computer scientists, IT professionals, etc.), and many other areas (e.g., health administration, business, public health, law, etc.). There is room for everyone in the big tent of informatics!

While our certificate and degree programs are at the graduate level (i.e., you need to have a bachelor's degree), our 10x10 ("ten by ten") course is open to anyone, even those who do not have a bachelor's degree.

An excellent way to get a broad-based introduction to the field is our on-line introductory biomedical informatics course. This course is offered in a number of flavors, and there are upcoming opportunities for you to enroll. Whatever path you take through the course, you can (assuming you are eligible for graduate study) get credit in our graduate program and be eligible to take more courses in our program if you are interested.

The introductory course is completely on-line and has been completed by about 1000 individuals in the last decade. It covers all the major aspects of biomedical and health informatics, with a focus on informatics applied to health care. It is offered using a variety of asynchronous distance learning teaching modalities, so you do not need to be present on-line at any specific time, although you do need to keep up with the work during the academic term.

One way to take the course is through our regular graduate program. OHSU is on an academic quarter system. Due to continued demand, the introductory course has been offered every academic quarter. The next offering is over the summer quarter, which runs from June 22 to September 11. The course will be offered again in the fall quarter, which runs from September 28 to December 13. To take the course by this pathway, you need to enroll in the OHSU Graduate Certificate program, which is open to anyone with a bachelor's degree. For more information, follow this link to our department Web site and click on the link to the Prospective Students Portal on the lower right:
http://www.ohsu.edu/dmice/

Another option to take essentially the same course is via the AMIA 10x10 program. This version of the course is offered in partnership with the American Medical Informatics Association (AMIA). The course is taught in the same on-line, asynchronous manner. It is offered over a slightly longer time period (decompressed with some "off" weeks) and adds an in-person session at the AMIA Annual Symposium, where all the students come together to meet and engage in additional learning. The AMIA Annual Symposium is one of the leading health IT meetings and will be held this year in San Francisco from November 14-18. Registration is already open for the next offering of the 10x10 course, which begins on July 30th and runs until the AMIA meeting. For more information, visit:
http://www.amia.org/10x10/partners/ohsu/
Or:
http://www.billhersh.info/10x10-2009.html

If you successfully complete the 10x10 course (and are eligible for graduate study), you can then get credit for the BMI 510 course in our graduate program. Once you are enrolled in the program, you can take additional courses. There is also a relatively easy pathway to advance beyond our Graduate Certificate into our master's degree program (and even the PhD program).

Here is a detailed outline of the introductory course content:

1. Overview of Field and Problems Motivating It
1.1 What is Health/Bio/Medical Informatics?
1.2 A Discipline Whose Time Has Come
1.3 Who Does Biomedical Informatics?
1.4 Problems in Health Care Motivating Biomedical Informatics
1.4 Seminal Documents and Reports
1.5 Resources for Field - Organizations, Information, Education

2. Biomedical Computing
2.1 Types of Computers
2.2 Data Storage in Computers
2.3 Computer Hardware and Software
2.4 Computer Networks
2.5 Software Engineering
2.6 Challenges for Biomedical Computing

3. Electronic Health Records
3.1 Clinical Data
3.2 History and Perspective of the Health (Medical) Record
3.3 Potential Benefits of the Electronic Health Record
3.4 Definitions and Key Attributes of the EHR
3.5 EHR Examples
3.6 Nursing Informatics

4. Clinical Decision Support; EHR Implementation
4.1 Historical Perspectives and Approaches
4.2 Medical Errors and Patient Safety
4.3 Reminders and Alerts
4.4 Computerized Provider Order Entry (CPOE)
4.5 Implementing the EHR
4.6 Use and Outcomes of the EHR
4.7 Cost-Benefit of the EHR

5. Standards and Interoperability; Privacy, Confidentiality, and Security
5.1 Standards: Basic Concepts
5.2 Identifier and Transaction Standards
5.3 Message Exchange Standards
5.4 Terminology Standards
5.5 Privacy, Confidentiality, and Security: Basic Concepts
5.6 HIPAA Privacy and Security Regulations

6. Secondary Use of Clinical Data: Personal Health Records, Health Information Exchange, Public Health, Health Care Quality, Clinical Research
6.1 Personal Health Records
6.2 Health Information Exchange
6.3 Public Health Informatics
6.4 Health Care Quality
6.5 Clinical Research Informatics

7. Evidence-Based Medicine and Medical Decision Making
7.1 Definitions and Application of EBM
7.2 Interventions
7.3 Diagnosis
7.4 Harm and Prognosis
7.5 Summarizing Evidence
7.6 Putting Evidence into Practice
7.7 Limitations of EBM

8. Information Retrieval and Digital Libraries
8.1 Information Retrieval
8.2 Knowledge-based Information
8.3 Content
8.4 Indexing
8.5 Retrieval
8.6 Evaluation
8.7 Digital Libraries

9. Imaging Informatics and Telemedicine
9.1 Imaging in Health Care
9.2 Modalities of Imaging
9.3 Digital Imaging
9.4 Telemedicine: Definitions, Uses, and Barriers
9.5 Efficacy of Telemedicine

10. Translational Bioinformatics
10.1 Translational Bioinformatics - The Big Picture
10.2 Overview of Basic Molecular Biology
10.3 Important Biotechnologies Driving Bioinformatics
10.4 Clinical Genetics and Genomics
10.5 Bioinformatics Information Resources
10.6 Translational Bioinformatics Challenges and Opportunities

11. Organizational and Management Issues in Informatics
11.1 Organizational Behavior
11.2 Organizational Issues in Failure and Success of Informatics Projects
11.3 Change Management

New York Times Article on Field, Profession, and Education

There is an excellent article about the emerging informatics profession and training for it in the Sunday, April 12 New York Times by Christine Larson:
http://www.nytimes.com/2009/04/12/jobs/12starts.html

This is a well-written article that describes the emerging informatics profession in these times of the Obama stimulus package and its health information technology adoption incentives. However, as newspaper reporters often do, she got a few things slightly wrong. This does not, however, detract from the overall article, which gets across the message well.

One thing slightly wrong was her quote of me, "The health I.T. people run the servers and install software, but the informatics people are the leaders, who interpret and analyze information and work with the clinical staff." First, I would not use the word "health" in front of the phrase "I.T. people" because "health I.T." is often used synonymously with the applications of informatics, such as electronic health records and clinical decision support systems. It is the I.T. people who do run the servers and install software, but the jobs of informaticians are not limited to being leaders and working with clinicians. Those with training in informatics can perform many other jobs in the health I.T. setting, such as project management, training, implementing quality or safety projects, and much more that involves knowledge of both I.T. and health care.

The reporter also states that some institutions have added programs within the last four years. OHSU's first degree program was actually launched in 1996, and we have been teaching via distance learning since 1999.

While the reporter rightly notes that educational programs "can bear a bewildering variety of names," I would not agree that medical and biomedical informatics are the same, nor that they only "focus on data that doctors need for treating patients." I would argue that they focus on more than just those things. Likewise, I would not completely agree with the definition that health informatics "programs often emphasize clinical data and health records." However, I do completely concur with her statement, "Even among programs with the same name, the emphasis may vary."

As most people know, I consider the terms "biomedical and health informatics" or "biomedical informatics" to be the broad umbrella terms. Subsumed under those are "medical informatics" or "clinical informatics," which refer to informatics applied in the clinical setting. "Health informatics" is somewhat orthogonal, which may also involve a focus on non-clinical aspects of informatics, such as personal health. One thing is certain: Our field needs to end this bewilderment and standardize our definitions!

Nonetheless, I believe this reporter did an excellent job overall, and it is great to see an article on our field and emerging profession in a prominent paper like the New York Times.

What is the Right Informatics Training for Me?

An individual considering spending part or all of their working time in health and biomedical informatics may find the decision of what career path and/or educational program to choose somewhat daunting. As I have noted elsewhere [1, 2], this reflects the fact that (a) informatics is still a maturing discipline, (b) there is no standard curriculum, program accreditation, or individual certification, and (c) the role of information technology (IT) in health and biomedicine is still evolving. Nonetheless, there is growing recognition of the need for better use of IT in clinical settings as well as biomedical research.

There is a growing -- though by no means complete -- consensus on the types of jobs performed in informatics. My view, based on the inventory of competencies developed by Covvey et al. [3], is that there are three general levels of informatics practice:

• Academic - an individual who does research and/or teaching, typically in an academic center
• Professional - an individual who works in an operational informatics setting for a majority of his or her working time, such as a Chief Information Officer, Chief Medical or Nursing Officer, or Project Manager or Leader
• Liaison - an individual who spends part of his or her working time as a local expert and interfacing with informatics or information technology professionals

Do you need to be a clinician to be trained and effective in a job in informatics? Do you need to know computer programming? The answers are no and no! Informatics is a very heterogeneous field, and there are opportunities for individuals from all types of backgrounds. One thing that is clear, however, is that the type of informatics job you assume will be somewhat dependent on your background. Those with health care backgrounds, particularly medicine or nursing, are likely to draw on that expertise for their informatics work in roles such as a Chief Medical or Nursing Officer. Those who do not have health care backgrounds still have plenty of opportunity in the field, but are more likely to end up in the wide variety of other jobs available, everything from a local project leader to a Chief Medical or Nursing Officer.

Most current informatics leaders also believe there is a growing need for “local experts” in informatics. As we know that one of the major success factors for an IT project is engagement of the user community, there will be a growing need for those who represent the “users” in a well-informed way.

It should also be noted that the lines between the above categories are fuzzy. The informatics leader at a large medical center may well need (or desire) the breadth of training of an academic informatician. Likewise, the local expert in a community hospital or large clinical practice may also want to have additional training at or near the level of an informatics professional. The amount of expertise among the levels, especially between expert and professional, may really be more of a continuum, with the expert advancing to the professional level as his or her career develops.

With this basic overview of the field, we can now move on to the basic question of this posting: what is the right informatics education for me to pursue? This discussion will emanate from the context of the educational program we have developed at Oregon Health & Science University (OHSU); other programs have some or all of the comparable levels of training.

The programs at OHSU have been developed in a building-block fashion. That is, coursework done at the lower levels can be carried forward to the higher levels. It should be noted that all of the programs at OHSU are currently at the graduate level, i.e., require a bachelor’s degree to enter. While there are some undergraduate informatics programs developing in the US, it is not clear whether the breadth of knowledge and experience can be obtained in a single baccalaureate or associate degree.

OHSU’s informatics programs are available both on our campus and via distance learning. We have successfully offered most of our courses and programs on-line for nearly a decade. Our program has evolved to the point where on-line and on-campus offerings are considered equivalent and are not distinguished on a student’s transcript. Distance learning does not mean “distant” learning. We have standardized on a number of technologies that provide high-quality and interactive education. Our courses are not correspondence courses, and require a reasonable commitment of one’s time for success. Almost all of the course activities are, however, asynchronous, meaning that students can access the material on their schedule as long as they keep up with the overall class.

Most of our courses, whether on-line or on-campus, are three-credit courses. As OHSU is on an academic quarter system, courses are 11 weeks in duration. A three-credit course typically means a commitment of 6-10 hours per week of work. Most courses have activities typical of university courses, with lectures (on-line classes typically use voice over slides), readings, term projects, homework, and examinations. You can access a demo version of the program's introductory course with the login/password bmi_demo/format.

One pathway into the OHSU program is the 10x10 Program. Run in partnership with the American Medical Informatics Association (AMIA), this program aims to train individuals at the Liaison level. The 10x10 moniker comes from a goal to train 10,000 health care professionals by the year 2010 in basic informatics so they can be local experts representing users in their communities. About 15% of people taking 10x10 pursue subsequent study in the OHSU graduate program.

The 10x10 course is an adaptation of the introductory course in the OHSU curriculum, with the addition of a 1-2 day in-person session covering additional material in an interactive manner. As such, the 10x10 course can be used for subsequent credit in the other OHSU programs pending successful completion of the course’s final examination (which is not required to complete 10x10). The topics in the curriculum of the 10x10 course would not surprise most people familiar with the informatics field and include:

• Overview of Field and Problems Motivating It
• Biomedical Computing
• Electronic Health Records
• Clinical Decision Support
• EHR Implementation
• Standards and Interoperability
• Privacy, Confidentiality, and Security
• Secondary Use of Clinical Data: Personal Health Records, Health Information Exchange, Public Health, Health Care Quality, Clinical Research
• Evidence-Based Medicine and Medical Decision Making
• Information Retrieval and Digital Libraries
• Imaging Informatics and Telemedicine
• Translational Bioinformatics
• Organizational and Management Issues in Informatics

The remainder of the programs build on the introductory course or 10x10. The Graduate Certificate program focuses on the core of biomedical informatics. After the introductory course, students take more advanced courses in areas such as clinical systems, information retrieval, and organizational behavior and management. They can also take additional electives as well as pursue practicum projects in their own communities. The Graduate Certificate program requires 24 credits, or eight three-credit courses, for graduation.

OHSU offers two master’s degree programs, which differ only in their culminating project. The Master of Science (MS) in Biomedical Informatics requires a master’s thesis, while the Master of Biomedical Informatics (MBI) is a “professional master’s” and requires a less-intensive capstone project. The master’s degree programs have two “tracks,” one in medical informatics and the other in bioinformatics.

The curriculum for each of the tracks is organized into “domains,” each of which are general curriculum areas and have both required and choices from among a list. The five domains in the medical informatics track are:

• Biomedical informatics - core courses in informatics science and applications
• Organizational and management sciences - business and management issues
• Computer science - practical introduction; concepts more important than programming
• Health and biomedicine - for non-clinicians
• Research methods - statistics plus quantitative and qualitative methods

The PhD program is a purely on-campus program, although PhD students can take individual courses that are offered on-line. Courses taken at lower levels of study are part of the PhD program “knowledge base” and can be carried forward into the program. The PhD program requires advanced study culminating in a dissertation consisting of independent research. All PhD students are supported with a tuition waiver, stipend, and benefits from training or research grants.

More information about the individual programs can be found on the OHSU Department of Medical Informatics & Clinical Epidemiology Web site. The 10x10 program is administered by AMIA and offered twice a year. The Graduate Certificate program has rolling admissions, i.e., students are admitted any quarter to begin classes the following one. The master’s and PhD programs, however, only have admissions once a year to begin in the fall quarter.

OHSU also offers a fellowship program funded by a training grant from the National Library of Medicine (NLM). Additional clinically oriented fellowships are offered in partnership with Kaiser Permanente Northwest (KPNW) and the Veteran’s Administration (VA). Two types of fellowships are available from the NLM training grant:

• Predoctoral - stipend and tuition support for some students in the PhD program
• Postdoctoral - for those with doctoral (e.g., MD or PhD) degrees who seek advanced training, with or without a degree (although most pursue a master’s degree)

The Kaiser and VA fellowships are for postdoctoral clinicians only and have a clinical service component.

References

1. Hersh WR, Who are the informaticians? What we know and should know. Journal of the American Medical Informatics Association, 2006. 13: 166-170.
2. Hersh W, Health and Biomedical Informatics: Opportunities and Challenges for a Twenty-First Century Profession and its Education, in IMIA Yearbook of Medical Informatics 2008, Geissbuhler A and Kulikowski C, Editors. 2008, Schattauer: Stuttgart, Germany. 138-145.
3. Covvey HD, Zitner D, and Bernstein R, Pointing the Way: Competencies and Curricula in Health Informatics. 2001, University of Waterloo: Waterloo, Ontario, Canada.

The Genesis of the 10x10 Course

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

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

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

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

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

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

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

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

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

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

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

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

Certification in Informatics

The current issue of Journal of the American Medical Informatics Association (JAMIA, March-April, 2009) contains several papers related to a process the American Medical Informatics Association (AMIA) is spearheading to establish a medical board sub-certification in clinical informatics (Detmer et al., 2009). I myself was involved in the training requirements paper that will be submitted (Gardner et al., 2009), along with the core curriculum (Safran et al., 2009), to the American Board of Medical Specialties. I note that the core curriculum looks a great deal like the OHSU medical informatics track curriculum of our biomedical informatics graduate program.

As AMIA is not a physician-only organization, another process is underway to establish certification for non-physician doctoral-level certification in clinical informatics. This will include doctoral-level health care professionals (e.g., those with PharmD, DNP, DPT, etc. degrees) as well as those with PhD degrees. At the same time, the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM), which certifies health information management professionals, has announced plans to establish a master's-level credential in health informatics.

What does all of this mean? First, it is important to understand the terminology. Certification applies to individuals, who obtain a credential that certifies their knowledge and skills to perform certain professional tasks, e.g., board certification of physicians, nurses, and other health care professionals as well as in other fields, such as a certified professional accountant (CPA). This is different from accreditation, which applies to educational programs and declares them capable of providing the training of individuals to attain certification. Sometimes programs are accredited without a corresponding formal certification, such as academic programs in public health and computer science.

Certification is usually applied to people in professional positions. It is not usually applied to those who are in academic or research settings. So while a Department of Medicine in a medical school may have its clinical faculty certified to practice medicine, it does not have corresponding certification for its research faculty (or for the non-practicing portion of the jobs of clinical faculty). Certification usually indicates that one has a competency to carry out a professional task, such as practicing medicine. In the case of informatics would most likely apply to those who work in operational settings, such as hospitals, clinics, health centers, and the like.

Certification would add some order to a field now where anyone can call themselves an informatician or offer an academic program. Indeed, there are a growing number of four-year colleges and even community colleges that are beginning to offer baccalaureate and associate degrees in the field. Of course, without a formal certification in informatics, there is no reason why they cannot. However, my own view is that informatics is the synergistic and unique intersection of health sciences, computer sciences, and management sciences, and as such, is difficult to impart with just a baccalaureate or associate degree. This does not mean that those individuals cannot work in health care settings, but rather that to truly do informatics professionally requires a level of training that combines expertise in multiple disciplines, and it is difficult to see how it can be imparted without some amount of graduate study.

Another challenge with certification will depend on how the training requirements are implemented. As many reading this know, I direct one of the largest academic informatics programs in the country, and its distance learning option has been extremely popular and successful. While I do believe that informatics expertise requires real-world experience, we have been able to provide that for those who have sought it in their education. Whatever on-site training requirements emerge, I do hope the educational and/or fellowship experience will allow sufficient flexibility for didactic coursework to be on-line and for hands-on training experience to be available in diverse settings and not necessarily just the sites of academic programs.

The implementation of certification and accreditation will bring a new level of maturity to our field. It will allow informatics professionals to gain the recognition of the important role they play in health and health care organizations. But hopefully it will be implemented in a way that maintains the intellectual, geographical, and other forms of diversity that exist in our field.

References

Detmer, D., Lumpkin, J., et al. (2009). Defining the medical subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 167-168.
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.
Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 158-166.