New IOM Report on Implementing the Learning Healthcare System: It's All in the Information

Some of the most important reports for setting the context of the work of informatics have been those from the Institute of Medicine (IOM). These reports have now spanned over 20 years, with many serving to raise awareness of problems and provide a context for informatics solutions. Some of the IOM's seminal reports have covered the topics of electronic health records [1, 2], telemedicine [3], computer networks and the Internet [4], privacy and security [5], medical errors and patient safety [6, 7], healthcare quality [8], health professions education [9], reducing costs while improving outcomes [10], and safety of health information technology [11].

More recently, these reports have coalesced around the notion of the learning health system, a system that learns from its experiences, incorporates the best science, and provides patient-centered care [12]. Additional reports have focused on issues that heavily involve informatics, such as developing the human and organizational [13] as well as digital [14] infrastructures for the learning healthcare system. The former Chief Science Officer of the Office of the National Coordinator for Health Information Technology tied its efforts to the notion of the learning healthcare system [15].

This past week, the IOM provided another "smash hit" in its series of reports. Entitled, Best Care at Lower Cost, this report notes the urgent need to address both the increasing complexity of the healthcare system as well as its continually increasing costs [16]. The report relates that many industries, from banking to manufacturing to transportation, operate with increasing coordination and efficiency in recent times, especially when aided by modern information technology. Yet healthcare is mired in the past, being highly uncoordinated and excessively labor-intensive.

The full report is available for viewing online and as a downloadable PDF. There are some condensed versions as well, including a report brief, the main recommendations, a list of the characteristics of a continuously learning healthcare system, and an infographic that highlights the main points. An article in JAMA also provides an overview of the report's motivations, findings, and recommendations [17].

The report asserts that implementing standard practices from those of other industries could result in:

• Records immediately updated and available for use by patients
• Care delivered the has been proven "reliable at the core and tailored at the margins"
• Patient and family needs and preferences are a central part of the decision process
• All healthcare team members are fully informed about each other’s activities in real time
• Prices and total costs are fully transparent to all participants in the care process
• Incentives for payment are structured to "reward outcomes and value, not volume"
• Errors are promptly identified and corrected
• Outcomes are routinely captured and used for continuous improvement

These results could be possible now because of human and technological changes that have been adopted in most industries, including:

• Substantial computational power that is affordable and widely available
• Network connectivity that allows information to be accessed instantaneously from almost anywhere
• Human and organizational capabilities that improve the reliability and efficiency of care processes
• The recognition that effective care must be delivered collaboratively by teams of clinicians and patients, with each playing a vital role in the process

The report was motivated in part by the conclusions of a previous report that noted annual excess costs of care in the US to be around $750 billion (out of $2.5 trillion expended), resulting in approximately 75,000 annual premature deaths. It grouped the causes of this waste and harm as due to:

• Unnecessary services provided
• Services inefficiently delivered
• Prices too high relative to costs
• Excess administrative costs
• Missed opportunities for prevention
• Fraud

Also identified in the report are four "characteristics of a continuously learning healthcare system." These include:

1. Science and informatics - real-time access to knowledge and digital capture of the entire care experience
2. Patient-clinician partnerships - engaged, empowered patients
3. Incentives - aligned for value with full transparency
4. Culture - instilled by leadership and with supportive system competencies

The report concludes with a series of recommendations for the continuously learning healthcare system group into three categories (verbatim):

I - Foundational Elements
1. The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
2. The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
II - Care Improvement Targets
3. Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.
4. Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.
5. Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
6. Care continuity. Improve coordination and communication within and across organizations.
7. Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
III - Supportive Policy Environment
8. Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
9. Performance transparency. Increase transparency on health care system performance.
10. Broad leadership. Expand commitment to the goals of a continuously learning health care system.

Informatics is of course central to the notion of the learning healthcare system by capturing, analyzing, and acting on data from the entire spectrum of care. There is another figure in the report that provides a "schematic" of the healthcare system that allows all of the critical informatics challenges and opportunities to be enumerated. This figure shows that the overall patient care experience begins from science, moving to evidence of what from the science improves patient care, followed by the delivery of that best care that will ideally result in the optimal patient outcomes and satisfaction. When any of these elements is carried out suboptimally, there are missed opportunities, waste, and harm. The only additions I would make to this figure would be feedback loops among the elements, i.e., the patient experience informs new science, evidence, and care, while the care experience feeds back to science and evidence, and so forth.

Informatics plays a role in each of these elements as well as the transitions between them. Starting with science, informatics increasingly plays a role in both driving and facilitating science. Informatics allows the science to learn from new discoveries in the data and also helps the scientist manage and analyze that data. It helps the clinical researchers select the best science to select and then evaluate for the evidence. Informatics also allows the best evidence to get implemented as care through methods such as clinical decision support. It also optimizes the care experience through quality measurement and improvement. In addition, informatics engages not only the patient and their caregivers but also other providers through health information exchange. Informatics also provides "safety rails" of sorts through maintaining safety, reducing error, facilitating privacy and security, and promoting adherence to standards. There is really no aspect of informatics that cannot be connected to this schematic.

By the same token, there is no aspect of informatics that cannot be related in some way to the continuous learning healthcare system. For this reason, this new IOM report presents a vision and all the grand challenges for the entire healthcare system as well as the role of informatics within it. Of course, vision alone is not enough, and we now must turn our attention to implementing it. Encouraging studies and reports are already coming out, such as the learning healthcare system operationalized at Group Health in Seattle [18], coordinated care projects implemented by Medicare to reduce hospital readmissions [19], the "Choosing Wisely" initiative to reduce unnecessary and potential harmful tests and treatments [20], and new science making the vast findings of genomics clinically "actionable" [21]. As with many other IOM reports, this report presents a robust context for the work of informatics to improve health and the healthcare system and points a way forward for doing so.

References

1. Dick, R., Steen, E., et al., eds. (1991). The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC. National Academies Press.
2. Dick, R., Steen, E., et al., eds. (1997). The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC. National Academies Press.
3. Anonymous (1996). Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC. National Academies Press.
4. Anonymous (2000). Networking Health: Prescriptions for the Internet. Washington, DC. National Academies Press.
5. Anonymous (1997). For the Record: Protecting Electronic Health Information. Washington, DC. National Academies Press.
6. Kohn, L., Corrigan, J., et al., eds. (2000). To Err Is Human: Building a Safer Health System. Washington, DC. National Academies Press.
7. Aspden, P., Corrigan, J., et al., eds. (2004). Patient Safety - A New Standard for Care. Washington, DC. National Academies Press.
8. Anonymous (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC. National Academies Press.
9. Greiner, A. and Knebel, E., eds. (2003). Health Professions Education: A Bridge to Quality. Washington, DC. National Academies Press.
10. Yong, P. and Olsen, L. (2010). The Healthcare Imperative: Lowering Costs and Improving Outcomes - Workshop Series Summary. Washington, DC. National Academies Press. http://iom.edu/Reports/2011/The-Healthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx.
11. Anonymous (2012). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC. National Academies Press. http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx.
12. Eden, J., Wheatley, B., et al., eds. (2008). Knowing What Works in Health Care: A Roadmap for the Nation. Washington, DC. National Academies Press. http://www.iom.edu/Reports/2008/Knowing-What-Works-in-Health-Care-A-Roadmap-for-the-Nation.aspx.
13. Olsen, L., Grossman, C., et al. (2011). Learning What Works: Infrastructure Required for Comparative Effectiveness Research. Washington, DC. National Academies Press. http://www.iom.edu/Reports/2011/Learning-What-Works-Infrastructure-Required-for-Comparative-Effectiveness-Research.aspx.
14. Grossman, C. and McGinnis, J. (2010). The Digital Infrastructure for a Learning Health System: Foundation for Continuous Improvement in Health and Health Care - Workshop Summary. Washington, DC. National Academies Press. http://www.iom.edu/Reports/2011/Digital-Infrastructure-for-a-Learning-Health-System.aspx.
15. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29. http://stm.sciencemag.org/content/2/57/57cm29.full.
16. Smith, M., Saunders, R., et al. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC. National Academies Press. http://iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx.
17. Redberg, R. (2012). Getting to best care at lower cost. Archives of Internal Medicine: Epub ahead of print.
18. Greene, S., Reid, R., et al. (2012). Implementing the learning health system: from concept to action. Annals of Internal Medicine, 157: 207-210.
18. Brown, R., Peikes, D., et al. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31: 1156-1166.
20. Cassel, C. and Guest, J. (2012). Choosing wisely: helping physicians and patients make smart decisions about their care. Journal of the American Medical Association, 307: 1801-1802.
21. Feero, W. (2012). Determining actionability of genetic findings in clinical practice. ACP Internist, July/August 2012. http://www.acpinternist.org/archives/2012/07/genomics.htm.

What is "DMICE," a "Track," a "Certificate?" The Jargon of the OHSU Informatics Program

In my paper that gave my definitions of the terminology of the biomedical and health informatics (BMHI) field, I noted the challenge of how confusing all the jargon could be. I realize now that this problem is exacerbated by the additional jargon we add on top of it in our educational program at Oregon Health & Science University (OHSU). Unfortunately, the complexity of our program makes there no simple solution, and the best approach is to try to define the jargon as simply and succinctly as possible.

So let me start with the first sub-question in the title of this post: What is DMICE? DMICE is the Department of Medical Informatics & Clinical Epidemiology, which is one of 26 academic departments in the School of Medicine at OHSU. A public university in the state of Oregon focused mostly on the health sciences, OHSU has Schools of Medicine, Nursing, and Dentistry, along with a School of Pharmacy administered jointly with Oregon State University. DMICE sits among other more traditionally named departments in the OHSU School of Medicine, such as Medicine, Surgery, and Medical & Molecular Genetics. As Chair of DMICE, I report to the Dean of the OHSU School of Medicine.

As in most departments in universities, DMICE has a wide variety of educational and research programs. One of those is the Biomedical Informatics Graduate Program. This is the umbrella term used to describe all of the educational programs dealing with informatics and related disciplines in DMICE. The program is offered at graduate level, i.e., students must have a baccalaureate degree to be admitted.

The Biomedical Informatics Graduate Program features several tracks, each of which represent a focus of study within BMHI. The tracks are partially overlapping, representing our view that our overall program is focused on the larger BMHI, even though students and professionals work within specific areas of the field.

Before there were tracks in the program, the original focus of the program was in clinical informatics, which was originally called medical informatics. We prefer to call this portion of the program the clinical informatics track now, which indicates its broader focus beyond informatics related to the work of medical doctors. Clinical informatics includes other branches of healthcare and even areas beyond the healthcare system, such as consumer health informatics. The clinical informatics track of our program focuses on informatics delivered mainly at the level of individual, whether in the role of a patient or as a consumer outside of the healthcare system.

The second track of our program, the bioinformatics and computational biology (BCB) track, has more of a focus on informatics at cellular and molecular level. The term bioinformatics refers to a focus on genomics and related areas, while the computational biology term indicates a strong emphasis on computational methods.

We recently added a third track to the program, the health information management (HIM) track. There is actually substantial overlap between HIM and clinical informatics, recognizing that HIM is evolving from management of paper records to electronic records. HIM has a different history from informatics as a so-called allied health profession, but it is increasingly moving toward electronic data systems in healthcare, i.e., clinical informatics. Our HIM track is accredited by the Commission on the Accreditation of Health Informatics and Information Management (CAHIIM), and students completing the program are eligible to sit for the Registered Health Information Administrator (RHIA) credential.

One of the advantages of the system of tracks is the ability to add additional tracks. I would like to see us add in the future a track for public health informatics, which would certainly have overlap with the clinical informatics and probably the others as well.

The tracks in our programs offer various degrees and certificates. One degree offered by all of the tracks is the Master of Science (MS). This was the original degree offered by the program and is a traditional research master's degree, which culminates in a thesis. The clinical informatics and HIM tracks also offer a non-thesis master's degree, sometimes referred to as a professional master's degree, the Master of Biomedical Informatics (MBI). The MBI has the same curriculum as the MS but replaces the master's thesis with a less-intensive capstone project. We also allow the capstone project to be an internship experience where the student gains real-world experience in an operational setting, such as a healthcare organization or a company.

Perhaps one of the lesser understood credentials in our program is the Graduate Certificate, which is offered in the clinical informatics and HIM tracks. Unlike master's degrees (which actually vary greatly but represent a generally known quantity), certificates between and even within different fields vary substantially. In many disciplines, the term Graduate Certificate is coming to represent a graduate-level educational experience that is not quite as much as a master's degree. In some universities, a Graduate Certificate is part of a continuing education or professional development program, sometimes even distinct from the graduate program. In our program, the Graduate Certificate is properly viewed as a subset of our master's degree (even though the eight three-credit one-quarter courses are enough to be a master's degree in some institutions). Students in the Graduate Certificate program take the same courses as those in the master's degree, only fewer of them.

The Graduate Certificate was developed when we first started offering distance learning courses in what we then called medical informatics. We thought that many of the students in our program who already had doctoral degrees would not be interested in a whole master's degree. Over time we did find that some were interested in a master's degree, so eventually expanded the distance learning offerings to that level.

Our graduate program also offers a Doctor of Philosophy (PhD) program in the clinical informatics and BCB tracks. (In reality, someone in the HIM track could progress to the PhD level in the clinical informatics track.) Just as the Graduate Certificate is a subset of the master's degree program (for the clinical informatics and HIM tracks), the master's degree programs are in turn a subset of the PhD program. We call the master's curriculum within the PhD the knowledge base, to which students add advanced research courses and a dissertation.

Because the higher-level programs are supersets of the more basic programs, we call this the building-block model of our program, indicating that students can start at the entry level for a given track and potentially progress all the way to the PhD (if their career goals warrant). The following figure depicts the building-block model of the program.

We also offer fellowship programs at both the predoctoral (PhD student) and postdoctoral (those with a doctoral degree already, who usually pursue a master's degree as a fellow) levels. Those who are fellows are mostly funded by training grants and other scholarships. Our main training grant is funded by the National Library of Medicine (NLM), a institute within the National Institutes of Health (NIH). In some ways, the fellowship program is a form of financial aid, as except for the funding provided and a work area, we treat fellows no different from other students.

There is some additional jargon from our program to round out this discussion. One is the 10x10 ("ten by ten") course. The 10x10 course is a program we started in partnership with our professional association, the American Medical Informatics Association (AMIA), in 2005. Its name was based on an estimated need to train 10,000 physicians and nurses (one each in all of the 5000+ US hospitals) in informatics by the year 2010. Of course we encouraged others, even non-healthcare professionals, to enroll in the course. The reason for mentioning the course here is that its curriculum is identical to the introductory course in the OHSU clinical informatics and HIM track, BMI 510 - Introduction to Biomedical & Health Informatics. In fact, those who complete the 10x10 course (which is a continuing education course) can optionally take the BMI 510 final exam and, if they obtain a grade of B or better, receive credit for BMI 510 in our graduate program. About 30% of the 1300+ people who have completed the 10x10 course have done so, and many have gone to further courses in the program. In fact, because of the building-block model, some of have progressed up from the Graduate Certificate to the master's degree programs and in two cases all the way to the PhD program.

Another item of jargon is the clinical informatics subspecialty. This refers to the new subspecialty for physicians that was recognized by the American Board of Medical Specialties in 2011. While plans for the certification process and training programs are still under development, this will represent a career pathway for physicians that gives professional recognition for the work they do in informatics. Unlike any other subspecialty in medicine, it will be available to physicians from all primary specialties, such as Medicine, Surgery, Radiology, and Pathology.

I hope this post clarifies and demystifies some of the confusing jargon of the informatics field and the educational program at OHSU. There is no easy answer to simplifying all this terminology, since there are so many distinct paths and credentials within the field. The approach is to try to understand it all from a comprehensive framework like the one I laid out here.

Data Entry: An Under-Discussed Grand Challenge for Informatics

Everyone, including this blog writer, has been touting the virtues of the vast troves of data already or soon to be available in the electronic health record (EHR), which will usher in the learning healthcare system [1, 2]. There is sometimes unbridled enthusiasm that the data captured in clinical systems, perhaps combined with research data such as gene sequencing, will effortlessly provide us knowledge of what works in healthcare and how new treatments can be developed [3, 4]. The data is unstructured? No problem, just apply natural language processing [5].

I honestly share in this enthusiasm, but I also realize that it needs to be tempered, or at least given a dose of reality. In particular, we must remember that our great data analytics and algorithms will only get us so far. If we have poor underlying data, the analyses may end up misleading us. We must be careful for problems of data incompleteness and incorrectness.

There are all sorts of reasons for inadequate data in EHR systems. Probably the main one is that those who enter data, i.e., physicians and other clinicians, are usually doing so for reasons other than data analysis. I have often said that clinical documentation can be what stands between a busy clinician and going home for dinner, i.e., he or she has to finish charting before ending the work day.

I also know of many clinicians whose enthusiasm for entering correct and complete data is tempered by their view of the entry of it as a data blackhole. That is, they enter data in but never derive out its benefits. I like to think that most clinicians would relish the opportunity to look at aggregate views of their patients in their practices and/or be able to identify patients who are outliers in one measure or another. Yet a common complaint I hear from clinicians is that data capture priorities are more driven by the hospital or clinic trying to maximize their reimbursement than to aid clinicians in providing better patient care.

Another challenge for clinicians is the time required for electronic data entry. There is no question that the 20th century means of clinical documentation, mostly consisting of scribbling illegible notes on paper, was much easier and faster than typing and/or clicking. While I think that few clinicians want to go back to hand-written notes, there is an appeal of their ease of use, at least for the person doing the entry.

Related to the time for electronic data entry is the "tension" between structured data, which makes aggregation and analysis easier, and "flexible" (or narrative) data, which allows the clinician to tell the story of the patient [6]. Many clinicians report that excess structuring of data (i.e., pointing and clicking) loses the story of the patient, although those who process the data know that structured data is easier to analyze.

An additional challenge for electronic data entry for clinicians is the shift of the focus from the patient to the computer. This was exemplified in a cartoon published earlier this year in JAMA that showed a 7-year-old's sketch of an exam room with the physician hunched over the computer, his back turned away from the patient and her family [7] (the sketch viewable at http://jama.jamanetwork.com/article.aspx?articleid=1187932).

An excellent example of the promise but limitations of current data entry systems was recently documented by Parsons et al. [8], who found in a wide sample of primary care EHRs in New York City that the accuracy of data for measuring breast cancer screening quality measures was highly variable due to differing practices in documentation, workflow, and related factors. While some physicians had the quality of their care measured accurately, for many others it was underestimated due to data limitations and not the care they provided.

I cannot claim to have easy answers to this grand challenge, but two related aspects of it sit in front of us:

1. We need to find better and faster ways for clinicians to enter data into the EHR that allow data whose quality is good enough to be re-used for other purposes, such as research, quality measurement and improvement, and public health.
2. We must reward clinicians for their efforts in entering high-quality data. We must allow them to see aggregate views of patients in their practices and be able to identify outliers. We must also engage them in research, quality improvement, and other system uses of their data.

In short, the concept of "garbage in, garbage out" still remains a problem for computers and information technology nearly a half-century after it was coined. In healthcare, we must give clinicians the best tools and incentives for them to participate in the learning healthcare system. For informatics, the problem of data entry is a grand challenge every bit as important as how to make use of its growing quantity, since the knowledge derived from that data will only be as good as the quality of what is input.

References

1. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29. http://stm.sciencemag.org/content/2/57/57cm29.full.
2. Greene, S., Reid, R., et al. (2012). Implementing the learning health system: from concept to action. Annals of Internal Medicine, 157: 207-210.
3. McCarty, C., Chisholm, R., et al. (2010). The eMERGE Network: a consortium of biorepositories linked to electronic medical records data for conducting genomic studies. BMC Genomics, 4(1): 13. http://www.biomedcentral.com/1755-8794/4/13.
4. Rea, S., Pathak, J., et al. (2012). Building a robust, scalable and standards-driven infrastructure for secondary use of EHR data: The SHARPn project. Journal of Biomedical Informatics, 45: 763-771.
5. Nadkarni, P., Ohno-Machado, L., et al. (2011). Natural language processing: an introduction. Journal of the American Medical Informatics Association, 18: 544-551.
6. Rosenbloom, S., Denny, J., et al. (2011). Data from clinical notes: a perspective on the tension between structure and flexible documentation. Journal of the American Medical Informatics Association, 18: 181-186.
7. Toll, E. (2012). The cost of technology. Journal of the American Medical Association, 307: 2497-2498.
8. Parsons, A., McCullough, C., et al. (2012). Validity of electronic health record-derived quality measurement for performance monitoring. Journal of the American Medical Informatics Association, 19: 604-609.

The Internationalization of 10x10

One of the most gratifying aspects of my work in informatics has been its international acceptance. I also enjoy my interactions with international colleagues, both professionally and personally. In addition, I obtain great satisfaction interacting internationally with students, whether they study under myself or others. All told, I enjoy making contributions that are known and valued around the entire world.

As I have written before, I have come to learn that many of the problems faced by informatics are global in nature, i.e., not unique to the United States. All who work in healthcare, public health, and research face challenges in collecting, organizing, and making best use of data and information. All types of information systems present challenges to workflow, usability, and value, among other things.

In recent years, one of my major collaborations has been with colleagues in South America, particularly in Argentina. One of these activities has been for them to translate my well-known 10x10 ("ten by ten") course into Spanish. They have offered the course all across Latin America, with nearly 1000 having completed it. The Spanish 10x10 course uses the same basic approach as my original course, consisting of a series of online units with an in-person session where students meet, learn more together, and/or present projects. While the original version of the Spanish course was a close translation of the English one, the content has now evolved to take on a more Latin American perspective. The core informatics issues are still global, but there are some regional differences, e.g., no delving into the details of HIPAA!

I am pleased to report that the collaboration with Argentina and its translation of the 10x10 course into Spanish has now come full circle, in that the Spanish course has made its way back to the United States via Puerto Rico. As Puerto Rico is fully eligible for funding through the HITECH programs, it has made efforts to help its eligible professionals and hospitals achieve meaningful use of electronic health records. One aspect of this has been the establishment of a regional extension center (REC), the Ponce School of Medicine REC (PSMREC). One of the activities of the PSMREC has been to bring informatics education to clinicians, and it has done this by engaging my Spanish-speaking colleagues and their version of 10x10 to create a new instance of the course, Certificado en Informática Médica para Puerto Rico. The course organizers invited me to participate in their in-person session in San Juan to kick off the course. I spent an enjoyable day with faculty and students, giving talks on the HITECH program as well as the secondary use of clinical data. I was also impressed with the backgrounds of the students taking the course, representing leaders from the REC, academic institutions, healthcare organizations, and others. It is always gratifying as an educator to help those you teach make a difference, which I am certain will happen in this course and what follows in Puerto Rico.

Another active collaboration involving the 10x10 course is in Singapore, with my colleague Dr. KC Lun of Gateway Consulting and the National University of Singapore. This offering of 10x10 uses my English version of the course, with my traveling to Singapore for the end-of-course in-person session. A total of 126 people have completed six offerings of the course over the last several years, with a seventh slated to start this month. I have enjoyed this offering of the course, both through the various people I have met in the Singapore healthcare community as well as the chance to learn about the Singapore healthcare system, which delivers high-quality care at about one-half the per-capita cost of the US.

I also remain active internationally in a number of other ways. I have served for six years as Chair of the Health and Medical Informatics Education Working Group of the International Medical Informatics Association (IMIA). I am a member of the Editorial Board of the International Journal of Medical Informatics. I serve on a number of institutional advisory committees in Europe, Asia, and Africa.

I cannot deny that being able to travel to many of these places has been one of the best perks of my job. Although the real beauty of this travel is that I do not just visit these places as a detached tourist. Rather, I enjoy being welcomed into the work and even home environments of my colleagues. I value seeing firsthand the informatics-related work that they do. I look forward to continuing my work with all of them.

Accolades for the Informatics Professor: Update

As readers of this blog know, I periodically point to other places on the Web where the Informatics Professor has been mentioned or honored. One recent accolade is an article in the magazine, For the Record, describing the recent update to the ONC Health IT Curriculum. I also wrote another article myself for HIMSS Clinical Informatics Insights, a perspective piece about the entire ONC Health IT Workforce Program.

Another accolade is being asked to serve on the (get ready for a mouthful!) Workforce Subgroup of the Certification and Adoption Workgroup of the ONC Health IT Policy Committee. The Health IT Policy Committee sets policy for ONC initiatives, including implementation of meaningful use. The Certification and Adoption Workgroup is tasked with making recommendations "on issues related to the adoption of certified electronic health records that support meaningful use, including issues related to certification, health information extension centers and workforce training." The Workforce Subgroup on which I will be serving is tasked with making "recommendations to the Health IT Policy Committee on ways to provide health IT education to all health care workers."

An additional accolade I have received is being elected as a Fellow of the American College of Medical Informatimusicology (ACMImimi). This honor is bestowed upon those who "see the perfect harmony found in combining healthcare, information technology and music" and manifest it by performing music in a public setting, in my case a recent rendition of some Neil Young songs at the National Library of Medicine Trainees meeting in Madison, Wisconsin on June 26, 2012.

ACMImimi is run by Ross Martin, MD, MHA, an accomplished informatician in many ways, but perhaps most distinctive by his making informatics concepts, especially the HITECH program, accessible via music. I have steered students in recent years to some of his most entertaining and educational pieces:
HITECH: An Interoperetta in Three Acts
The Meaningful Yoose Rap

MOOCs Coming to Informatics?

A few months ago, I wrote a post about the new development of massive open online courses (MOOCs) and what disruptive innovation they might have on higher education. While noting that academic biomedical and health informatics sat at the intersection of the two industries having the least amount of disruptive innovation - healthcare and higher education - I did note that MOOCs could have an impact, if they ever came to our field.

Well now they have, and it turns out that one of my projects is playing a major role in their development. The Health Informatics Forum, an international blogging and social network site for informatics, has started to turn the entire ONC Health IT Curriculum into a MOOC. They recently posted Unit 1 of Component 1 on their site, with announcement of plans to add a new component every four weeks.

How successful will this effort be? There will certainly be value in providing learning materials to the entire world. But there are some caveats. First, as those of us in the ONC Health IT Curriculum project have noted, the materials are designed more for educators than learners. While they provide a rich amount of learning substrate, like all good education they require more, including a teacher, a structured learning process, and ideally fellow learners. In addition, any professional educational experience also requires a connection to the real world through practical opportunities, such as internships. Furthermore, in any rapidly changing field, such as health IT and informatics, the curricular materials must be regularly updated and otherwise improved. It will be interesting to see how sites like The Health Informatics Forum address this latter challenge, particularly as the field evolves. (For example, the Stage 2 meaningful use rules as well as new HIPAA regulations are due out in the next few weeks. As of now, neither of these are covered in the ONC curriculum.)

One final caveat is that the total quantity of these materials represent about 20 college-level courses. This means that any one person will require a great deal of time and effort to work through all of them. By the same token, there are a number of advanced informatics topics that are not covered by the ONC curriculum, such as secondary use of data, natural language processing, and analytics, to name a few. Still, I will be eager to see how this all works out, and hope to lend my expertise to increase its likelihood of success.

It turns out that The Health Informatics Forum is not the only organization that has utilized the totality of the ONC materials as a large learning experience. Two other organizations have done this as well, one of which charges a fee, which is allowable under the Creative Commons license under which the materials have been released:

• http://www.vcn.org/healthcare/online-courses/hit
• http://education.ehrtrainingacademy.com/course/category.php?id=24

The discussion around MOOCs also continues to flourish in the press. The New York Times has run a series of articles, mostly focused on the two efforts led by Stanford (Coursera) and Harvard/MIT (edX) but now expanding to include other universities in their partnerships. This has included articles about the expansion of Coursera as well as the the early experiences of Coursera and edX and one call for caution:

• Expansion of Coursera
• Early experience of Coursera
• Early experience of edX
• One professor's concern about the impersonal aspects of online learning - I actually disagree that online courses need to be impersonal, but I do agree there is no better form of education that the close interaction between the teacher and learner.

It is still too early to tell how these efforts will fare, and what their impact will be on higher education. As one who has been teaching online for 13 years, I can say that learning is very possible, and often desirable, especially when the learner is separated from the learning experience by distance or time. We have many students in our distance learning program at Oregon Health & Science University (OHSU) who desire our education but live far from Oregon and/or work during the time that on-campus classes are offered. In fact, we have a number of "local distance" who live in the area but value the convenience of the online classes.

But our courses at OHSU are anything but MOOCs. They feature direct interaction from our faculty. Furthermore, students can participate in and get credit from structured practicum and internship experiences. This leads one to wonder whether MOOCs might become a means to deliver higher education rather than complete experience in and of themselves. Nonetheless, it will be interesting to see the outcome of this natural experiment in education.

Mapping the AMIA Clinical Informatics Core Content into the OHSU Biomedical Informatics Curriculum

One of the most exciting developments in the clinical informatics field in recent years has been its designation as a new medical subspecialty. Even if one is not a physician, the professional recognition of the work of clinical informatics is important. Hopefully we will see others who work professionally in informatics achieve comparable professional recognition. Indeed, AMIA has established an Advanced Interprofessional Informatics Certification Task Force to explore the best approaches for certification of non-physician informaticians.

Another valuable outcome of the clinical informatics certification process was the development of the core content for the clinical informatics subspecialty (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. http://jamia.bmj.com/content/16/2/153.full.pdf+html.). This content is by no means limited to physicians and should serve as the basis for the curricular content for all clinical informatics programs.

We recently undertook an analysis of the curricular content in our Biomedical Informatics Graduate Program at Oregon Health & Science University (OHSU) to see how our existing courses mapped into the AMIA core content. We were pleased to discover that just about everything in it is covered by one or more courses in our master's degree program. We are planning to undertake a more detailed analysis in the future to make sure our curricular materials are covered adequately and reflect the most state-of-the-art content. But in the meantime, I am pleased to report that we will be ready to provide education for certification in the field when such programs are ready to be launched. The results of this analysis can be viewed in this PDF file.

Search Industry Track at SIGIR 2012

Although the entirety of the ACM SIGIR 2012 conference, from tutorials to cutting-edge research, will be of interest to those concerned with search systems and algorithms, the Industry Track on the Wednesday (August 15) of the conference will likely be of most interest to those in “tech” industry. In the Industry Track, a series of speakers from all of the major search vendors, most of whom are also sponsors of the conference, will present on their latest works. More information on this track is available, as is information on the conference itself from a local perspective.

The opening speaker of the Industry Track will be Eric Brown of IBM Research, who will present an overview of IBM’s Watson and the DeepQA technology upon which it is built, and explore future applications of this technology. Another speaker will be Andrei Broder of Google, who will discuss the growing field of “computational advertising,” i.e., how algorithms use the context of the user and his or her search terms to display the most appropriate “sponsored” pages. Also speaking will be Daniel Rose of A9.com, a subsidiary of Amazon.com, who will discuss the “democratization” in their new CloudSearch service.

Among the other speakers will be search industry veteran, Sue Dumais of Microsoft, who famously said in 2007 that if search was still using user-entered text boxes in ten years that she should be fired from her job. She will describe the twin problems of putting user context into search as well as putting search into the user’s context. (We are halfway there in 2012 and still using search boxes; maybe someone will ask if she worries for her job!)

Other Industry Track speakers will include John O’Neil of Attivio (Entity Sentiment Extraction Using Text Ranking), Ilya Segalovich of Yandex (Making Web Search More User-Centric: the State of Play and the Way Ahead), and Azarias Reda and colleagues at LinkedIn (Related Searches at LinkedIn).

The track will wrap up with the 2012 Industry Panel consisting of four distinguished panelists who will be asked to represent the likely viewpoint of a particular group or “vertical” while responding to a series of questions notified in advance.  Trystan Upstill of the Search Quality Team at Google will represent “large scale web search”; Jerome Pesenti, Chief Scientist at Vivisimo / IBM, will represent “enterprise search”; Krishna Gade, Engineering Manager at Twitter will represent “real-time and social search.” Stephen Robertson, Emeritus Professor at City University, London and Microsoft Research will represent “academic research” and Diane Kelly, University of North Carolina Chapel Hill and author of an influential monograph on user-involved evaluation, will take the all-important perspective of “users.”  The audience, too, will have their say!

Update on the OHSU ONC University-Based Training Grant

Just as the end of the ONC Health IT Curriculum project is in sight, so is the end of the ONC University-Based Training (UBT) Program. OHSU's UBT grant to train 135 Graduate Certificate and 13 Master of Biomedical Informatics (MBI) students is entering its home stretch.

We have filled all of our UBT slots available for funding, which means that no further students will be funded by this mechanism. We have graduated about half of those who entered the program, i.e., 65 (of 135) Graduate Certificate students and 5 (of 13) MBI students. The remainder will graduate by the end of the grant in June, 2013. As noted in an earlier posting (and additionally below), we have had many success stories from our graduates.

Between the new careers we have enabled our graduates to have, as well as the new positions we have been able to create for faculty and staff in the program, I have no qualms in saying our program is a "job creator."

The UBT program has also been invaluable to the larger OHSU biomedical informatics educational program. It has provided resources allowing the expansion of services by our program, including a practicum and internship program as well as career counseling. In fact, a major goal for our program in the coming year is to find a way to sustain the infrastructure that the ONC grant has allowed us to develop.

Another notable accomplishment for the program was two of our UBT graduates being invited to attend a special two-day event at the Department of Health and Human Services (HHS) and the White House over June 18-19, 2012. The 200 invited attendees included physicians, other healthcare providers, informaticians, vendors, and government officials. The two OHSU attendees were MBI graduate Larry Bannister and Graduate Certificate graduate Dr. Mark Johnson, both of whom reported back as provided below.

Larry Bannister

Mr. Bannister, working formerly in the IT industry, has a position with the Certification Commission for Health Information Technology (CCHIT) in Chicago, IL as a Test Manager. He reported back from the event:

On the first day of the “festivities” here in D.C., we went to the U.S. Dept. of Health and Human Services (HHS). This is housed in the Hubert J. Humphrey Building, which is just a block away from the White House. We started with a  “meet-and-greet” affair for the participants to mingle and for all of us to meet various ONC officials. I met another Oregonian, Dr. DeOna Bridgeman, and we had our picture taken with Dr. Farzad Mostashari. Pretty cool. I also met another OHSU graduate from the biomedical informatics program, Dr. Mark Johnson, and we compared notes about our experiences in the program. After this, we were ushered into a room where you could imagine many a high-powered press conference was given and we heard interesting things about what the ONC is doing to increase the awareness of health IT. Dr. Mostashari gave a very interesting and motivating speech, which was followed by an appearance and speech by HHS Secretary Kathleen Sebelius. The mood throughout the whole event was very upbeat. I know this is an odd thing to say, but I think these folks really, really like what they are doing and seem to be caught up in the excitement of being part of a “movement.” I guess, since I am an HIT person too, I am as well. And, I might add, it is a bipartisan movement, at least from my perspective. Us Republicans see the benefit of HIT and pin many hopes on it as well.

We ended the day by going to various breakout sessions. The session I went to was on “Interoperability & Exchange.” We ranged all over those topics, but the most interesting thing to me was concerning the S&I Framework. This framework, based on the Direct standard, is basically a process for qualifying various entities that want to become participants in an HIE of some kind. Although they have gone down the road a ways, especially in the east coast states, they are also working on another model, the Nationwide Health Information Network, or NwHIN, which is based on the Exchange standard. The ONC recently issued a governance RFI in which they solicited feedback from the HIT community at large concerning NwHIN, and so they solicited comment from us too. However, it was mostly physicians there, with a few policy wonks and just a few technical folks (like me), so although they solicited feedback on the RFI, what the crowd wanted to talk about was:  1) trust issues as the basis of success for HIE’s, 2) payment models that held back most MDs and hospitals from getting on board, and 3) for those MDs and organizations that were onboard, how the current Direct project was so lame and cumbersome (their experience being with portals a.k.a. HISPs). Anyway, they urged everyone to read the “66 questions”  from the RFI and chip in their two cents. I think that is a very good thing for any HIT person to do, as well, since it will probably affect us in the future. After the session broke up we continued to talk amongst ourselves for at least a half hour – everyone was so interested in what others were doing.

On the second day we went to the White House. On that day, ONC announced that over 110,000 eligible physicians and over 2400 eligible hospitals had received meaningful use incentive payments. It was an interesting experience, just getting into the White House. The meeting was held in one of the three (or is it four?) buildings that make up the White House, i.e., the Eisenhower Executive Office Building. Security was tight getting in, just as you would expect, but we had to wait outside in stifling heat and humidity for a while since there were so many of us to process through. My suit was pretty wrinkled and sweaty before I finally sat down in the air-conditioned room where we had our meeting. Just as the day before, we heard some opening comments by Dr. Mostashari and other ONC/HHS officials, but then we had a town-hall session where people from the audience were given time at the microphone and had their say. Dr. Mostashari moderated this and kept us on task and on time.

The topics ranged all over the place so I can’t focus on any one in particular, but they mainly focused on HIE experiences, usability, and war stories. Here are just a few that I took notes on:

• “All RHIOs are not the same” was the opening comment. One MD from Colorado complained about how his HIE experience was dismal and expensive and wondered what could be done better
• A number of physicians related success stories about how they made HIEs work well. Dr. Larry Garber from Massachusetts related how their EHR interfaced to 5 different hospitals, multiple health plans and specialty practices and did such magical things as automatically incorporate both labs and notes from a patient’s ER visit into their medical record
• There seemed to be just as many stories about how peer-to-peer interfaces came up faster and worked better as there were stories concerning coordinated HIE efforts using Exchange.
• A number of calls for standards for things as diverse as: vendor-neutral medical record exchange; history & physical documentation; a single HL7 standard that meant the same thing to everyone;  a standard for alerts and finally, usability standards.
• A number of different funding models for HIE were discussed:  government funding models, payer-funded models and shared payer-physician-vendor split funding models, to name a few.
• Most interesting to me was the story of a group practice that had created a large general –purpose, table-oriented templating system that was easily customizable to produce notes/documentation at any level of detail for each provider’s requirements for their medical documentation.
• Usability popped up again when someone called on vendors to consider usability issues at the very earliest stages of system design and then there was a short diversion into the “geek gap”.  Someone said that EHRs shouldn’t be designed by “propeller heads” (which even though I’m a software engineer, I heartily agree with) but rather, it has to be a well-coordinated, collaborative process.

Anyway, I could not take notes on all that was being said – I was just fascinated and caught up in the moment so often.  It was great and I left feeling really jazzed about the future of this field. There are some exciting times ahead and I’m glad to be part of this thing, myself.

Mark Johnson

Dr. Johnson was formerly a Staff Physician in Critical Care Medicine at the University of Wisconsin Hospital and Clinics. Since obtaining his Graduate Certificate at OHSU, he has joined the Carle Clinic in Urbana, IL as a critical care physician and informatician. Dr. Johnson reported:

It was both an honor and a humbling experience attending events at the White House, ONC, and HHS.  With recent completion of a critical care fellowship at University of Wisconsin-Madison, and a Graduate Certificate in clinical informatics at OHSU (funded by the ONC), I have been uniquely positioned to be a clinician leader in the realm of health IT and the ICU. This led to multiple job offers and acceptance of my dream job (combining health IT and critical care) near family and my alma mater in Urbana, IL. I was thrilled to share my story with others around the nation.

During the flight to DC, I wrote down some of my hopes and worries about the trip. Hoping to: connect with others, share thoughts on redesigning the healthcare system, be a part of the national health IT agenda and synchronize my own career with the timetable and aligned goals. Worried that: I may not fit in, be behind the times, and be too closely tied to a single vendor.

On June 18th, I arrived at the HHS building and mingled with other “Health IT Vanguards,” as the ONC dubbed us. There I met Larry Bannister, another OHSU trainee, and heard about how he was able to retool, combining his IT experience and biomedical informatics training to secure a position at CCHIT, an important entity in the health IT world. I also met a young surgical trainee from Duke, a primary care physician from Oregon, and others. The room had a lot of energy from the “Vanguards” as well as the ONC leadership. I was excited to meet Dr. Farzad Mostashari, National Coordinator for Health IT, and share my story. I thanked him (and ONC) for the training grant.

Next, we were ushered to an auditorium, with speeches from Dr. Mostashari and the Secretary of HHS, Kathleen Sebelius. I was impressed that they seemed tapped into what was going on around the nation. Dr. Mostashari spoke about us as vanguards and our ability to “walk through walls”, to breakthrough barriers to get things done. And he spoke about aiming toward a “healthcare system that does right,” noting, “we don’t always do it right but we always try to do it right.” Secretary Sebelius spoke about how government creates conditions, and creates paths, and that we should share our stories so that others may follow our paths, and to “keep pushing forward.”

These speeches were followed by media training, on how to effectively share our stories with the media. Breakout discussions capped of the event at HHS, and I attended the “Leveraging Health IT for Quality Improvement” discussion. Here I highlighted that there was much knowledge in the room, and across health systems (in regards to how best implement health IT), but there was no system to share this knowledge. Also that ONC can serve as a lever/feedback mechanism to the vendors.

The next morning was the main event at the White House complex. Here was a broader speech by Dr. Mostashari, panelists from around the nation, and a lively Q&A session. Key topics discussed included health information exchange, usability, vendor relations, and “moving beyond the data.” Key quotes that I wrote down included from a vendor “we want ONE standard,” and “ONC needs to hold their [vendor’s] feet to the fire.” From a health IT clinician “culture eats strategy for lunch.” From Dr. Mostashari re: HIE “lots of different models work,” we need to stop “hand fitting pipes,” and set “common rules of the road.”

In summary, the event was enlightening in how government works, what the nation’s agenda is moving forward, and a first-hand sample of what is going on around the country. Most of my hopes leading up to the event were realized and the worries were allayed. I was thrilled to be a part of the event, and feel called to continue working toward a health system that does right. This adventure continues locally in my new position in Urbana, IL and will unfold as I build on my ONC funded training at OHSU.

Below are pictured two of the ONC Health IT Vanguards, Mr. Bannister (left) and Dr. Johnson (right).

The entire ONC Workforce Development Program has been beneficial to our students, our program, and our country. I recently had the opportunity to write an overview of the ONC Workforce Development Program two years into the program for the HIMSS Clinical Informatics Insights publication.

Postscript: The White House visit by the OHSU students was also covered in the online School of Medicine News.

Where Do OHSU Biomedical Informatics Students Live?

We have always known that OHSU students in the distance learning biomedical informatics program live all over the country, and the world, but thanks to Dr. David Dorr and Kelly Jones-Weir, we now have a graphical depiction of their distribution across the United States. Each dot (star) in the figure below represents where one student lives.

The concentration of dots in the Portland area represents an interesting phenomenon. We have a number of what we call "local distance" students in the program, who are people that live in the Portland area yet are enrolled in our distance program. For the most part, these individuals prefer the flexibility that the on-line courses offer. Some may have jobs or other obligations during the day when on-campus classes are offered. One nice aspect is that they take part in other program activities, such as our local research conferences and other events.

In addition to students from the US, we also have students from a number of different countries. Some of these students come to Oregon to study but others are distance learning students (who even come on-campus for our hybrid short courses, as all master's students must do). The countries with one or more students in the program include:

• Argentina
• Australia
• Canada
• Egypt
• India
• Israel
• Kuwait
• New Caledonia
• Saudi Arabia
• Singapore
• Thailand
• United Kingdom
• Zimbabwe

While our program is somewhat US-centric, since those who practice informatics in the US must understand the nuances (some might say craziness) of the US healthcare system, I have also noted in the past that many informatics problems and solutions are global in their nature.

Search Industry Titans and Academic Researchers Converging This Summer in Portland for Information Retrieval Research Conference

Although search is ubiquitous in this age of broadband Internet and mobile wireless devices, and search engine companies are among the most prominent icons of the Internet, there are still many challenges to overcome and new functionality to be developed for search systems. The field of information retrieval (IR) long predates the mainstreaming of search and developments such as the name of the leading search engine becoming a verb (i.e., “Googling”). This field has studied and evaluated the systems and algorithms that established the foundation for modern systems.

The leading research conference in IR, spanning three and a half decades, is the ACM Special Interest Group on Information Retrieval (SIGIR) Conference. The 35th Annual ACM SIGIR Conference will be held this year in Portland, Oregon from August 12-16 at the Portland Downtown Waterfront Marriott. Registration for the conference is now available.

The SIGIR 2012 meeting begins on Sunday, August 12, 2012 with a day of Tutorials, some of which are half-day and two of which are full-day. Also taking place on that day is the Doctoral Consortium, an event that is limited to doctoral students who have been selected to participate. The day finishes up with a Welcome Reception at the conference hotel.

The first day of the regular conference is Monday, August 13. After a breakfast for newcomers to SIGIR, the Opening Ceremony will launch the conference. At this ceremony will be the presentation of the winner of the triennial Gerard Salton Award, who will give a plenary talk. This will be followed by Paper presentations in three simultaneous tracks through the rest of the day. Monday evening will cap off with Posters and Demos, along with a reception.

On Tuesday, August 14, the day will begin with a second Keynote Speaker. This will be followed by Paper presentations in three simultaneous tracks through the rest of the day. Tuesday evening will finish with the Conference Banquet just down the street from the hotel at the Portland World Trade Center.

The final regular day of the conference is Wednesday, August 15. This day will also Paper presentations in three simultaneous tracks through the day. In addition, a separate Industry Track will feature presentations from various researchers and leaders in the commercial sector. This day will also feature the annual SIGIR Business Meeting, with box lunches provided.

The conference will end on Thursday, August 16 with a day of four workshops open to all attendees.

The local host of the meeting is the Oregon Health & Science University Department of Medical Informatics & Clinical Epidemiology. I am honored to serve as the General Conference Chair, as my career in IR applied in the health and biomedical domain spans more than two decades.

Although this event is not one of the massive trade shows one might find about search and related events, this event will bring about 600 researchers from academia and industry, along with students and others, to Portland. Industry sponsors for the event lined up so far include Microsoft Research, Baidu, Google, eBay, IBM Research, Cambridge University Press, Morgan & Claypool Publishers, and Springer. The conference will draw participants from 30-40 countries.

For more information about the conference and to register to attend it, visit the conference Web site at:
http://sigir.org/sigir2012/

OHSU Graduation: As Always, a Time to Celebrate

This week was Oregon Health & Science University (OHSU) graduation, marking a celebration of accomplishment for students from a wide array of disciplines. It was also a milestone for the OHSU biomedical informatics graduate program, marking our 15th year of the program having graduates. I have always enjoyed attending the graduation ceremony, basking in the success of our graduates as well as the program as a whole. I have missed the ceremony only in those 15 years. Below is a picture of some of the graduates and faculty after the ceremony.

We had our annual department banquet the evening before graduation. This is another event I never miss. We honor all graduates who show up for the event as well as the staff who make success possible for them. This year I flew in from Singapore just six hours before the banquet.

I hope our new alumni will also take advantage of and participate our Alumni Steering Committee, which we have stood up in an attempt to remain engaged with them. I hope we can offer our alumni enduring value long after they complete their studies, from continuing education to networking among their peers. I also hope the alumni will serve as ambassadors to inform others about the rewards of careers in the field and the value of studying at OHSU.

As of this graduation, we have now awarded a total of 455 degrees and certificates to 425 people. (The reason for more people than certificates and degrees is that some have received more than one.) The distribution includes:

• Doctor of Philosophy (PhD) - 11
• Master of Science (MS) in Biomedical Informatics - 71
• Master of Science in Biomedical Informatics (MBI) - 107
• Graduate Certificate in Biomedical Informatics - 266

Some accomplishments of our individual programs are also worth noting. One of our graduates from the MS program and also a National Library of Medicine Postdoc Fellow, Dr. Paula Scariati, won the School of Medicine Best Master's Thesis Award for her thesis entitled, Making choices about breast cancer screening: A decision aid for women between the ages of 38 & 48. Our Office of the National Coordinator for Health IT (ONC) University-Based Training (UBT) Grant had its first six MBI graduates along with numerous Graduate Certificate Program graduates. Our health information management (HIM) track continues to thrive, with nine graduates now having successfully passed the Registered Health Information Administrator (RHIA) certification exam, six of whom are graduates of the UBT Graduate Certificate Program.

Who is an OHSU informatics alumnus? There is no single type of person who can be described. These graduates and students come from heterogeneous backgrounds. The enrollment in all of our programs combined is about 30% physicians, 34% other clinicians, and the remainder from a wide array of other backgrounds. About 6% of our students have an MBA, while 4% have an MPH. But we also have a number of other notable fields represented, including law, biosciences, library and information science, and computer science, to name a few.

Of course, our primary goal is not just to achieve numbers. Rather, we aspire (and believe we have succeeded) in providing an education to a wide diversity of people who will be successful in careers applying information and associated technologies to improve peoples' health. To that end, I am personally gratified that our program has touched so many lives and enabled individuals to launch successful careers in biomedical and health informatics.

Disruptive Innovation Coming to Higher Education? The Role of Massive Open Online Courses

The notion of disruptive innovation was popularized by Clayton Christensen [1, 2], and is described as change, usually technological, that causes upheaval of an entire industry sector. We have seen plenty of disruptive innovations in the modern digital era, as the marketplace for products such as books, newspapers, photography, banking, and travel has undergone profound change. Who takes pictures using film or regularly walks into a bank anymore? Who does not spend at least part of their reading time doing so on electronic devices, increasingly those held in the hand, such as smartphones or tablets?

There is a certain irony for those of us who work in academic biomedical and health informatics. On the one hand, we are immersed in the technologies that have caused so much disruptive innovation, i.e., computers, the Internet, and the World Wide Web. On the other hand, those of us in academic informatics apply our work at the intersection of two fields that may be the lone remaining holdouts for disruptive innovation, namely healthcare and education.

We can debate in another post whether disruptive innovation will ever come to healthcare. There are some signs, but I am not holding my breath. Recent developments in higher education, however, potentially portend profound change coming. Being in higher education for a livelihood, I naturally have great interest in the consequences of disruptive innovation within it.

This potential disruptive innovation in higher education comes in the form of what some call massive open online courses (MOOCs). This area has received a great deal of attention lately with the foray of some of the leading US universities into this area, namely Stanford, Harvard, and Massachusetts Institute of Technology (MIT). It has garnered attention in the popular media [3-6].

As most readers of this blog know, I have great enthusiasm for online learning. A good deal of my work in the last decade has focused on the fusion of educational technology with biomedical and health informatics [7-10]. However, the result has mostly been education based on the traditional model of the professor teaching and interacting with a relatively modest number of students.

MOOCs change the calculus of online learning in a much more profound way. Stanford computer science professors Andrew Ng and Daphne Koller have been at the forefront, adapting and delivering their courses to massive audiences [4, 6]. They are part of a new technology venture led by Stanford and including several other big-name US universities called Coursera. Not to be left out, Harvard and Massachusetts Institute of Technology have also launched a similar initiative.

Despite their high profiles, these are not the first such initiatives to disseminate high-quality higher education content via the Web. Two other initiatives, Udacity and the Khan Academy, have been doing this for several years. Resources like the University of Pittsburgh Epidemiology Supercourse have been in existence even longer.

Will these MOOCs lead to disruption in higher education? The cynic in me notes that Ng and Koller are not changing the core Stanford product, where a small number of highly smart students pay a substantial amount of money in the form of Stanford tuition for the privilege of being on the Palo Alto campus and getting a degree from Stanford. I also note that these courses are mostly basic courses, and not the more advanced knowledge that might help someone apply this information. The content is "open" in the sense of being available to anyone, but not in the "wiki" sense of being improved upon in a massive way.

But the optimist in me with the goal of spreading knowledge via technology cannot help but be impressed at the uptake and reach of these courses. I certainly enjoy the global interaction I have through the various educational activities in which I take part in on the Internet. Even Facebook can sometimes be a platform for disseminating knowledge and doing what I enjoy most as an educator, which is getting people to both delve into deeper layers of fact as well as apply them in larger contexts and intellectually principled ways.

As is often the case, the ultimate reality will likely fall somewhere in the middle. Clearly the Web provides an unprecedented vehicle for knowledge dissemination. But education is so much more than a student absorbing knowledge. There is also the in-depth application of that knowledge for real-world purposes. I cannot help but wonder, for example, whether the Coursera natural language processing (NLP) course will enable a student to be able to implement a system that can detail with all the nuances of the narrative text generated by clinicians in the electronic health record. One thing that clinical informatics has taught us is the lack of predictability of technological interventions in healthcare settings.

Of course we have shown to our satisfaction at Oregon Health & Science University (OHSU) that pretty much all types of learning can be delivered online. But we have also learned that an education involves more than learning. Early on in our foray into distance learning, I was struck how we had developed, without deliberately trying to do so, a virtual community. When students join our program, they not only get access to our courses, but also our faculty, their student colleagues, and our connections to the larger informatics world, including our connections to industry. Even the staff in our office provide a conduit for their new journey into careers and other activities in the field.

But I am also, in a sense, part of this MOOC world, due to the Office of the National Coordinator for Health IT (ONC) Curriculum Project that has absorbed a great deal of my professional time, effort, and passion over the last couple years. All of this potential for disruptive innovation of informatics education therefore comes at a time of critical juncture for our field. We have been fortunate to have, for the first time in the history of our field, substantial federal investment, not only in the form of subsidized education for students, but also in the development of the ONC curricular materials. The verdict is still out on what impact the curricular materials will have on informatics education and training in the long run. But with the ARRA funding for them winding down, we are at a critical juncture in finding ways to sustain them (if we believe they are important) once the grant for them ends at the end of 2012.

In conclusion, I view the potential for disruptive innovation in higher education as a challenge and an opportunity. While I am not worried it will make my world dissipate like camera film or bank tellers, I do know the ride will be bumpy. But in the end, I am confident that education will be improved and possibly more cost-effective. I am also confident of the continued role I will play in advising students and others about directions and opportunities for our field. And if things ever do settle down, we can move on to the real challenge for disruptive innovation, which is the healthcare industry!

References

[1] Christensen, C. (1997). The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail. Boston, MA. Harvard Business School Press.
[2] Christensen, C. (2012). Disruptive Innovation, in Soegaard, M. and Dam, R., eds. Encyclopedia of Human-Computer Interaction. Aarhus, Denmark. The Interaction-Design.org Foundation. http://www.interaction-design.org/encyclopedia/disruptive_innovation.html.
[3] Lewin, T. (2012). Instruction for Masses Knocks Down Campus Walls. New York Times. March 4, 2012. http://www.nytimes.com/2012/03/05/education/moocs-large-courses-open-to-all-topple-campus-walls.html.
[4] Markoff, J. (2012). Online Education Venture Lures Cash Infusion and Deals With 5 Top Universities. New York Times. April 18, 2012. http://www.nytimes.com/2012/04/18/technology/coursera-plans-to-announce-university-partners-for-online-classes.html.
[5] Brooks, D. (2012). The Campus Tsunami. New York Times. May 3, 2012. http://www.nytimes.com/2012/05/04/opinion/brooks-the-campus-tsunami.html.
[6] Friedman, T. (2012). Come the Revolution. New York Times. May 15, 2012. http://www.nytimes.com/2012/05/16/opinion/friedman-come-the-revolution.html.
[7] Hersh, W., Junium, K., et al. (2001). Implementation and evaluation of a medical informatics distance education program. Journal of the American Medical Informatics Association, 8: 570-584.
[8] 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.
[9] Hersh, W. (2007). The full spectrum of biomedical informatics education at Oregon Health & Science University. Methods of Information in Medicine, 46: 80-83.
[10] Hersh, W. (2010). The health information technology workforce: estimations of demands and a framework for requirements. Applied Clinical Informatics, 1: 197-212.

ONC Health IT Curriculum: Version 3 and Beyond

Although my last update of the ONC Health IT Curriculum project was relatively recently, there is much news to report, warranting another posting. Some background information for understanding some of the details in this posting in available in a prior posting announcing the availability of Version 2 of the curriculum. It should be remembered that while these curricular materials are freely available to anyone, they are really more designed for educators than students. There is nothing to keep any student from anywhere from downloading them, but they are less designed to be a health IT curriculum "out of the box" and more designed for instructors to develop into materials for specific learners, with additional perspectives, exercises, and even wisdom to be added accordingly.

Probably the most important news is the release of Version 3 of the curriculum. This will be the final version of the curriculum released under the original ONC Health Curriculum Development Centers Program grant. Version 3 is available to anyone to freely download from the National Training & Dissemination Center (NTDC) Web site.

The uncompressed size of the Version 3 materials is 11.2 gigabytes, contained in 18,072 files. As noted in the table below, the 20 components of the curriculum contain 9,974 Powerpoint slides and audio lasting over 136 hours (5 days, 16 hours, and 4 minutes, to be precise!). The NTDC search engine for the text-based files contains 38,181 unique words indexed. A manually constructed topical index is also available.

Of course, not all of the curriculum consists of narrated slides. There are also exercises, including those involving hands-on use of an educational version of VistA for Education (VFE), a fully functional version of the VA VistA electronic health record system, which is also included with the materials. A screen shot of VFE is shown below.

Some additional good news is each of the five universities in the program have been awarded a no-cost extension (NCE) to continue work on the project. In the case of OHSU, this will extend our grant through December 31, 2012. During the NCE time period, we will continue to provide support via the NTDC as well as prepare updates of the components for which we are responsible. Another activity during the NCE period will be to enhance VFE, including exploring the option of providing a fully open-source version that runs on all versions of Windows. (The current version requires a license for Intersystems Cache, which is only freely available to educational institutions.)

A final activity of the five Curriculum Development Centers during the NCE period will be to explore options for sustainability of the curricular materials beyond the end of the NCE period. We are investigating options to obtain funding to maintain, support, and extend the materials while continuing to make this resource freely available.

Spring Renewal in Information Retrieval

Every spring I get a chance to renew my work in information retrieval (IR, also known as search), the area where I first started my research career over two decades ago. My other interests in informatics policy, workforce development, and education, along with my leadership and administrative work, now tend to crowd out the time I devote to IR research and related activity, but I always stay engaged.

The main reason for having my renewal each spring is the teaching of my course in our graduate program, BMI 514/614 - Information Retrieval. At a minimum, this leads me to refresh the updates on the Web site for my book on IR in health and biomedicine. I also often have an opportunity for students to work on projects of mine, especially since the course usually fits well within the annual challenge evaluations of the Text Retrieval Conference (TREC) or ImageCLEF.

This year has been even more of a renewal than most years. Part of the reason is my serving as General Conference Chair of the ACM Special Interest Group in Information Retrieval (SIGIR) 2012 conference, which will be held this August here in Portland. (More in the blog to follow!)

I have also re-engaged in TREC through helping to organize topic development and relevance judgments for the TREC Medical Records Track, which was launched last year to combine aiming to apply IR tools and techniques to retrieval-related problems in electronic health records.

I also recently happened across some fun IR things on the Web. One is ability to create a Wordle from one's scientific publications in the large SciVal collection (see image below). The words that show up largest should surprise no one! Another is the new ability in Google Scholar to set up a profile for one's scientific work, showing most cited works, one's h-index, and other information.

Witness to a Great Public Health Informatics Achievement

Last week, I had the opportunity to participate in a ceremony at the Centers for Disease Control and Prevention (CDC) announcing their Public Health Informatics Fellowship being recognized as a Registered Apprenticeship by the Department of Labor (DOL). This potentially sets the stage for public health informaticians to become a DOL standard occupational code, which means they would appear in DOL labor statistics. This is good news, and hopefully will lead to DOL recognizing other types of informaticians in their statistics.

I went to the meeting to represent AMIA, and had a chance to deliver these remarks:

My name is Dr. William Hersh, and I am Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University in Portland, Oregon. I attend this meeting representing the 4000 members of the American Medical Informatics Association (AMIA), the professional society for health-related informatics, and bring words from our President and CEO, Dr. Kevin Fickenscher, who unfortunately could not be here today.

Today, AMIA recognizes the tremendous accomplishment of the CDC’s Scientific Education and Professional Development Program Office in their collaboration with the Department of Labor. The establishment of CDC’s Public Health Informatics Fellowship Program (PHIFP) as a Department of Labor (DOL) Registered Apprenticeship and the laying of the foundation for a standard occupation code for public health informaticians represent a very significant milestone in the decade-long effort by AMIA and its members and leaders to address the crucial issues of informatics workforce development.

The mere fact that the Department of Labor may soon give informaticians a workforce code is very encouraging.  The designation will help the nation realize its ambitions for supporting a fully-interoperable, data-driven learning healthcare system.  Key to this ambition are informaticians of all stripes, not only public health but also clinical, nursing, and even bioinformatics.

In 2001, I and more than 400 AMIA member experts and thought leaders gathered for the organization’s Spring Congress meeting here in Atlanta to develop a national agenda for public health informatics. The resulting 74 recommendations emerged with themes reflected in the CDC/DOL’s decision. Our stakeholders recognized the need to be engaged in coordinated activities related to public health information. They also forecasted the need for informatics training throughout the public health workforce.

A decade later, AMIA experts revisited the national agenda at the 2011 Spring Congress meeting, where we came up with recommendations supporting the need for informatics workforce development and underlining informatics crucial role in the future of public health and healthcare.

Many of us in AMIA are involved in complementary efforts in workforce development in other areas of informatics. I myself have had the opportunity over the last two years to play key roles in the health IT workforce development programs of the Office of the National Coordinator for Health IT, both training professionals in clinical informatics as well as developing the national health IT curriculum focused initially on community college programs but now freely available to the entire world.

Public health informatics is embedded in these efforts, as those in clinical informatics must comprehend how the public health system can benefit from our federal investment in adoption and meaningful use of electronic health records. This is exemplified at my institution, OHSU, where a CDC public health fellowship graduate serves on our faculty and teaches a course in public health informatics to a predominantly clinical informatics student body.

AMIA members will continue to lead the national discussion on informatics workforce development and on what is needed on the front lines of public health. Together with leadership from the federal government, NGOs, public health organizations, associations and specialty societies and business we know informatics professions will grow.  We are encouraged that the CDC/DOL’s ‘public health informaticians’ designation can open the door for other informatics-related designations to follow.

Informatics Professor Elsewhere on the Web

I have had the opportunity to have my blog-related work featured elsewhere on the Web. Some of these sites get more traffic than my own blog.

One site where I have been having edited versions of my blog posts re-posted is HITECH Answers. All of the postings can be found by searching on the tag assigned to them indicating they are from me. HITECH Answers also features a radio show called MULive, where I was the guest on April 3, 2012. (The audio archive of the show can be accessed by registering or going straight to audio link.)

Another site re-posting some of my blog entries of pertinence to internal medicine physicians is the American College of Physicians. Some of my postings are available on ACP Internist, aimed at all internists, while others are available on ACP Hospitalist, aimed at hospitalist physicians.

Postscript: Shortly after this entry was posted, Dr. Kevin Fickenscher, new President and CEO of AMIA, called out a recent posting of mine.

From Implementation to Analytics: The Future Work of Informatics

I am occasionally asked whether the work of informatics will be "done" when everyone is finishing implementing electronic health record (EHR) systems. Sometimes the query is further qualified by, "once everyone gets their HITECH money."

My answer is always an emphatic "No!" There is no question that some informatics implementation activity may slow down when healthcare organizations are no longer fueled by pursuit of HITECH incentive dollars. These activities may be impacted even further by bottom line woes that are likely to impact healthcare no matter what the outcome of healthcare reform, or whatever other distractions come along, such as ICD-10.

I often further qualify my answer by noting that for many of us, the real interesting work of informatics begins when the EHR platform is in place and we can truly start to do interesting things with the data. These are the so-called "secondary uses" or "reuses" of clinical data [1], things like quality measurement and improvement, improved clinical research, or indeed the "learning health system" first envisioned by the Institute of Medicine [2] and put in the context of the HITECH investment by Friedman et al. [3]. Some call this the "optimization" stage of EHR implementation [4].

One buzzword that is used increasingly in healthcare (and was already in use outside of healthcare over the last few years) is analytics. As with all buzzwords, there is a copious volume of material that has been written. I find a couple books by Tom Davenport and associates [5, 6] to provide good overviews. Davenport is Research Director for a company in Portland called the International Institute for Analytics. A recent primer by The Advisory Board Company, a healthcare consulting firm, gives a good overview of analytics in the context of healthcare [7].  Another recent report comes from PwC, which paints a similar picture of the near future, although (to my content!) describes this as clinical informatics (rather than analytics) [8], The phrase business intelligence is sometimes used to describe this work, and I suspect we will see another phrase, big data, appearing more frequently, especially with the recent Obama Administration initiative in this area [9].

The Advisory Board Company primer nicely paints an overview of the use of analytics and business intelligence in healthcare. They distinguish between different uses of the data, each requiring a higher level of analysis and complexity:

• Descriptive - reporting and querying of data to identify problems and solutions
• Predictive - modeling, forecasting, and simulating outcomes based on the data
• Prescriptive - recommend the best course of action based on the data

Of course, those of us who work in clinical informatics know that gleaning value from clinical data is challenging. Indeed, those who have learned from implementation in the trenches may be best qualified to understand the limitations of their data. As I often say, documentation is not usually the highest priority for busy clinicians. Indeed, it is often what stands between a tired clinician at the end of the day and being able to go home for dinner. Clinical data also suffers from the lack of standards in structure and terminology of data, and it is often fragmented across different systems, both within and across different healthcare organizations.

Nonetheless, the growing platform of electronic clinical data, fueled initially by EHR adoption and now augmented by efforts at health information exchange in the proposed rules for Stage 2 of meaningful use, point the way forward [10]. Regardless of one's political views of healthcare reform, it is clear that the system needs to change to become more accountable and efficient. This will be drawn out with the move to new delivery systems, such as accountable care organizations [11]. Thus, analytics and related activities are the future of clinical informatics, realizing the goal of my definition of the field, which is the use of information to improve individual health, healthcare, public health, and biomedical research [12].

References

[1] Safran, C., Bloomrosen, M., et al. (2007). Toward a national framework for the secondary use of health data: an American Medical Informatics Association white paper. Journal of the American Medical Informatics Association, 14: 1-9.

[2] Olsen, L., Aisner, D., et al., eds. (2007). The Learning Healthcare System - Workshop Summary. Washington, DC. National Academies Press.

[3] Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29. http://stm.sciencemag.org/content/2/57/57cm29.full.

[4] Walker, J., Richards, F., et al., eds. (2006). Implementing an Electronic Health Record System New York, NY. Springer.

[5] Davenport, T. and Harris, J. (2007). Competing on Analytics : The New Science of Winning. Cambridge, MA. Harvard Business School Press.

[6] Davenport, T., Harris, J., et al. (2010). Analytics at Work: Smarter Decisions, Better Results. Cambridge, MA. Harvard Business Review Press.

[7] Adams, J. and Klein, J. (2011). Business Intelligence and Analytics in Health Care - A Primer. Washington, DC, The Advisory Board Company. http://www.advisory.com/Research/IT-Strategy-Council/Research-Notes/2011/Business-Intelligence-and-Analytics-in-Health-Care.

[8] Anonymous (2012). Needles in a haystack: Seeking knowledge with clinical informatics, PriceWaterhouseCoopers. http://www.pwc.com/us/en/health-industries/publications/needles-in-a-haystack.jhtml.

[9] Anonymous (2012). Obama Administration Unveils “Big Data” Initiative: Announces $200 Million in New R&D Investments. Washington, DC, White House. http://www.whitehouse.gov/sites/default/files/microsites/ostp/big_data_press_release_final_2.pdf.

[10] Copoulos, M., Raiford, R., et al. (2012). The Next Chapter - First Look at the Proposed Rule on Stage 2 of Meaningful Use. Washington, DC, The Advisory Board Company. http://www.advisory.com/Research/IT-Strategy-Council/Research-Notes/2012/~/media/Advisory-com/Research/ITSC/Research-Notes/2012/The-Next-Chapter-Stage-2.pdf.

[11] Fisher, E., McClellan, M., et al. (2011). Building the path to accountable care. New England Journal of Medicine, 365: 2445-2447.

[12] Hersh, W. (2009). A stimulus to define informatics and health information technology. BMC Medical Informatics & Decision Making, 9: 24. http://www.biomedcentral.com/1472-6947/9/24/.