Informatics Professor Postings Motivate Articles and Talks

Some items of interest motivated by prior postings from the Informatics Professor blog!

First, OHSU published one of its ongoing advertisements in the Opinion section of a recent Sunday Oregonian about healthcare reform that featured my views on how biomedical informatics will enable information use to improve healthcare quality, safety, and cost (as described in a prior blog posting). The views are consistent with OHSU's eight principles for healthcare reform, one of which is, "Supports more effective deployment of information technology, including but not limited to portable electronic health care records."

Second, the university published a piece that described my trip and Health Affairs article that motivated my prior post on "global truths."

Finally, I was recently invited to give a talk at the University of Michigan, where I gave a talk motivated by another recent post about informatics now living in a HITECH world. There are links to a video of my talk as well as my slides with references.

Informatics is a Field of Global Truths

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

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

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

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

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

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

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

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

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

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

Some interesting recent articles

With the increasing visibility of informatics careers, due in large part to ARRA/HITECH funding, comes increasing attention from the press about opportunities for training. Here are three recent interesting articles:

1. An overview of the 10x10 program in a health care workforce publication.
2. An article on career opportunities in clinical informatics, including an opportunity to meet some clinical informaticians.
3. An article on informatics opportunities in clinical and translational research. (Important point about this article: although clinical informatics is getting most of the press these days, it is important to remember there are other areas of the field that also provide opportunity, including informatics applied to clinical and translational research.)

Informatics Now Lives in a HITECH World

The flurry of activity from the Office of the National Coordinator for Health IT (ONC) in late 2009 laid out the implementation plans of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the economic stimulus package). The scope of programs was so immense that few aspects of the biomedical and health informatics field will be unaffected by HITECH. I think we can plainly say that informatics now lives in a HITECH world.

The discipline of biomedical and health informatics has had an increasingly important and visible role in individual health, healthcare, public health, and biomedical research in recent years. But HITECH will impact virtually every aspect of our field. It will certainly define the path and set the implementation priorities for hospitals and physician offices implementing their electronic health records (EHR). HITECH will drive the standards agenda for health data and information. It will also set the bar for privacy and security matters. Finally, HITECH will drive the academic informatics agenda through its impact on research programs (the SHARP program), demonstration projects (the Beacon program), and education (the health IT workforce funding initiatives).

There will, of course, be some activity outside the confines of HITECH. More fundamental research and training of future researchers will continue to be the purview of the National Library of Medicine (NLM). Informatics will continue to play a key role in the Clinical and Translational Science Award (CTSA) program of the National Institutes of Health (NIH). Likewise, the Agency for Healthcare Research and Quality (AHRQ) will likely continue its quality and comparative effectiveness research agendas with the heavy utilization of health IT. But even all of these programs will be impacted by HITECH's provisions and regulations concerning EHR data, its driving of the research agenda, and its influence on curricula in educational programs.

There has been much written in detail about various aspects of HITECH. Probably the best big picture overview is the New England Journal of Medicine article by the National Coordinator himself, Dr. David Blumenthal. This paper lays out the vision of "meaningful use" of health information and the ONC's planned path for achieving it. There are also a number of Web sites and blogs that maintaining ongoing information and commentary about the programs. These include:

• Geek Doctor blog - I have to commend Dr. Halamka for keeping us up to date with a very readable overviews of the emerging programs, regulations, technologies, etc.
  
• HIMSS - Also has a nice site, some of which is limited to members only, that also is kept up to date well
  
• AHIMA - Also starting to provide materials on meaningful use and related topics as well
• HISTalk - this more eclectic blog provides other interesting perspectives
  

There are many other interesting and informative sites, and I am not meaning to slight any of those by not including them. But the above sites are good entry points for those wishing to learn more about how HITECH will drive the EHR implementation agenda in the coming years. Google and other search engines can also be very helpful for finding more information, as can professional organizations to which readers may belong and that provide their perspectives. A nice consultant-style overview is provided by David Classen and Erica Drazen of CSC Corp..

It is important to remember that the goals of HITECH are ultimately rooted in improving individual health, healthcare, and public health. The goal is not adoption for the sake of technology. All HITECH rules, regulations, incentives, programs, etc. are linked to one of five underlying goals for the healthcare system:

1. Improving quality, safety and efficiency
2. Engaging patients in their care
3. Increasing coordination of care
4. Improving the health status of the population
5. Ensuring privacy and security

The financial incentives for EHR adoption are enshrined in two key documents that were released in late December, 2009. Both of these documents are interim documents, with 60-day comment periods before being finalized in the spring. These documents are:

• The Notice of Proposed Rule-Making (NPRM) - the rules for how incentives for meaningful use will be funded through Medicare and Medicaid reimbursement by the Centers for Medicare and Medicaid Services (CMS)
  
• The Interim Final Rule (IFR) standardizing what will be required to achieve meaningful use of EHRs by ONC
  

The NPRM defines eligible professionals and hospitals who can qualify for the meaningful use incentives. It stipulates what these professionals and hospitals must do over what time frame to achieve the incentive payments. Meaningful use is defined to consist of three requirements:

1. Use of certified EHR technology in a meaningful manner
2. Utilize certified EHR technology connected in a manner that provides for the electronic exchange of health information to improve the quality of care
3. Using certified EHR technology, the provider submits information on clinical quality measures

The NPRM defines three phases of increasing criteria and dates by which they must be accomplished to receive incentive payments. These phases were formerly named by the year that providers needed to implement them - 2011, 2013, and 2015 - but are now called stages, with the maximum incentive dollars received by those who implement them by those dates (i.e., stage 1 in 2011, stage 2 in 2013, and stage 3 in 2015). Eligible professionals and hospitals who implement them at later dates receive less funding, and all who do not implement stage 3 by 2015 are assessed a penalty through decreased Medicare or Medicare reimbursement.

The stages of adoption and their key features are as follows:

• Stage 1 - electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, implementing some clinical decision support tools, and initiating the reporting of clinical quality measures and public health information.
• Stage 2 - expand on Stage 1 to focus on continuous quality improvement at the point of care and the exchange of information in the most structured format possible.
• Stage 3 - focus on promoting improvements in quality, safety and efficiency by encouraging decision support, patient access to self-management tools, access to comprehensive patient data, and improving population health.

The NPRM presents the requirements for Stage 1 use of an EHR by hospitals and professionals in a meaningful manner. There are 23 criteria, which differ slightly whether for hospitals or professionals (pp. 103-108). Each is tied back to one of the five healthcare outcomes goals listed above. Some of the better known and more widely discussed criteria include:

• Use computerized provider order entry (CPOE) for orders (any type) directly entered by authorizing provider. One of the differences between hospitals and professionals is that the former are required to use CPOE for 10% of all orders whereas professionals are required to use it for 80%.
• Implement drug-drug, drug-allergy, and drug-formulary checks.
• Maintain an up-to-date problem list using ICD-9 or SNOMED.
• (Professionals only) Use electronic prescribing for 75% of all prescriptions.
• Exchange key information electronically among providers of care and other patient-authorized entities.
• Provide summary care record for 80% of care transitions.
• Provide electronic syndromic surveillance data electronically to public health agencies.
• (Professionals only) Provide patients with electronic access to their information for 10% of all patients.
• Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities.

Some of these criteria are open to interpretation and it is likely some will be modified when the final rule is issued. Many organizations have taken issue with various aspects of these criteria, usually arguing that the definitions are vague and/or they are not likely to be achieved, even for organizations that already have advanced EHR implementations.

The NPRM also lists the quality measures that meaningful users must report on in Stage 1. There are listed 35 clinical quality measures in nine categories for which hospitals must report to meet the meaningful use criteria (pp. 152-162). All of the measures have been endorsed by the National Quality Forum, and 25 have been adopted by the Hospital Quality Alliance. However, only nine of the measures are currently in use in Medicare's pay-for-reporting program, meaning that hospitals may face significant challenges in implementing the new measures if they are all adopted in the final rule. Hospitals will be required to report on all quality measures for which they have any applicable patients, not just for measures applicable to their Medicare patients.

For eligible professionals, the NPRM has a list of 90 quality measures that are grouped into 15 categories by specific medical specialties (pp. 143-151). Professionals must only report on measures for the category of professional in which they fall.

The IFR provides a definition of certified EHRs and an initial set of standards, implementation specifications, and certification criteria for EHRs. It creates standards for certified EHRs in four categories: content, vocabulary, transmission, and privacy/security. Certified EHR Technology is defined by the IFR as consisting of a Qualified EHR that has been certified by an authority designated by the Department of Health & Human Services (in a process to be determined). A Qualified EHR consists of an electronic record of health-related information on an individual that:

• Includes patient demographic and clinical health information, such as medical history and problem lists.
• Has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to health care quality; and exchange electronic health information with, and integrate such information from other sources.

Of course, as Dr. Blumenthal notes in his New England Journal of Medicine article, achieving the goals of HITECH and meaningful use will not happen with the financial incentives alone. There needs to be an infrastructure that will support the path to getting there. He notes a number of programs that are also funded under HITECH that will help hospitals and professionals reach meaningful use, especially primary care physicians in under-resourced practices. About $2 billion of ARRA funding has been devoted to these programs.

One substantial supporting program will be the Health IT Regional Extension Centers (RECs). About 70 RECs will be funded with $643 million to provide guidance, mainly to small primary care practices, in achieving meaningful use. Because there will be 70 programs, some larger states will have more than one REC while some smaller states will participate in multi-state RECs. These programs will have some similarity to the long-standing agricultural extension service that farmers have relied on for years to improve the capabilities of their farms.

Another key component to achieving meaningful use, likely familiar to readers of this blog, is development of the health IT workforce. The details of these programs have been described in previous postings, but essentially two types of programs will be funded. One will be the funding of five regional community college consortia to achieve 51,000 trained workers over five years (10,500 per year, starting in the fall of 2010) in six specific job roles. The other program will be the funding of universities to train another 1000-1500 individuals per year over three years for six additional higher-level job roles. Also funded under this initiative will be Curriculum Development Centers, mainly to assist community colleges, and a certification examination for graduates of the community college programs. A total of $118 million will be funded under these programs.

Additional funding will go for the following programs (and some additional ones in Dr. Blumenthal's paper and not listed here):

• State-based health information exchange (HIE) - $564 million in grants to the states to develop HIE programs.
• Beacon communities - $235 million to fund up to 15 communities that provide exemplary demonstration of the meaningful use of EHRs to bring out measurable improvement in the quality and/or efficiency of healthcare and/or public health.
• Strategic health information advanced research projects (SHARP) - $60 million for four collaborative research centers in the areas of: Security for Health Information Technology, Patient-Centered Cognitive Support, Healthcare Application and Network Platforms, and Secondary Use of EHR Data
  

I think it is safe to say that ONC and the rest of the government have "played their cards" in the implementation of HITECH, and the above rules and programs will drive the agenda of biomedical and health informatics and related health IT for years to come. These efforts now define what the key functions of EHR systems will be, how hospitals and professionals will fund their use, and what quality measures hospitals and professionals will need to report. The agenda for HIE will now be more clearly defined and very focused at the level of individual states. These programs also define the pathways for various professionals to enter the workforce and provide funding for them. Finally, leadership for both demonstration projects as well as the research agenda will be funded through the Beacon and SHARP programs.

Some ONC leaders have stated that HITECH is a "down payment" on health care reform. Of course, given the state of the health care reform debate as I write this in mid-January, I am not sure what the final payment will be or what healthcare will be in place as these programs are implemented. I do hold the opinion that HITECH is more likely to succeed if we transform our healthcare system to one that better values quality and efficiency, but even under the present system, it is likely to result in some positive improvement.

This is a defining moment for the informatics field. Never before has such money and attention been lavished on it. HITECH provides a clear challenge for the field to "get it right." It will be interesting to look back on this time in the years ahead and see what worked and did not work. Whatever does happen, it is clear that informatics lives in a HITECH world now.

A New Year's Moment to Reflect

The year 2010 will mark my 20th year at Oregon Health & Science University (OHSU). I arrived at OHSU in 1990 as a newly minted Assistant Professor, fresh out of a three-year medical informatics fellowship in Boston that followed my medical training (medical school and internal medicine residency in Chicago). I have seen a great deal of change in our field since my tenure in it began, but I don't believe there has been anything quite like this past year, 2009.

I remember quite vividly as 2009 began. While I was excited at the election of our new president and his fresh hope for change, I was more than a little concerned about the onset of the economic recession and its impact on the finances of OHSU. Based on what we were hearing, I was having some serious doubts about the viability of OHSU and our Department of Medical Informatics & Clinical Epidemiology, as cuts to the small but essential amount of support (about 5% of our overall budget) we received from the university looked threatened. Furthermore, the potentially draconian cuts in other departments greatly threatened institutional morale.

Within a month or two of the new year, however, a different picture began to emerge. Something called the American Recovery and Reinvestment Act (ARRA, also known as the economic stimulus package) had just come to be, and within it, something called the Health Information Technology for Economic and Clinical Health (HITECH) Act promised unprecedented new support for health information technology (HIT). I even played a small role in the development of ARRA, contributing a few words that made it into what became Section 3016, the portion legislating support for health IT workforce development, working with the staffs of my Congressman David Wu and one of my state's Senators, Ron Wyden. (ARRA has also greatly benefited some, but not all, of the other departments at OHSU.)

In addition to new acronyms that are now household names (at least for those of us in informatics), such as ARRA and HITECH, new phrases appeared in the vernacular, mostly notably "meaningful use." As an educator and frequent speaker on the topic, the constant unveiling of new details made it a challenge to keep all my slides up to date.

The year of unprecedented activity came to a head in the last month of 2009. The trickle of funding opportunity announcements (FOAs)turned into a torrent, with the Office of the National Coordinator for Health IT (ONC) laying out its implementation of the vision of HITECH. The tight mid to late January deadlines for these FOAs released in December led a colleague to quip that ONC stood for the "Office of No Christmas" (to which I added, "Office of No Chanukah" for those of a different religious persuasion). Like many, I have spent a good deal of this year's Christmas break working on proposals for the FOAs.

On the second to the last day of the month and year, ONC, along with the Centers for Medicare and Medicaid Services (CMS), released the Notice of Proposed Rulemaking (NPRM) for the "meaningful use" criteria that will guide the distribution of financial incentives for EHR adoption under HITECH. Further released was the interim final rule (IFR) on Standards & Certification Criteria, the initial set of standards, implementation specifications, and certification criteria for the interoperability, functionality, utility, and security of health IT. A good starting point for digesting all the information associated with these is the ONC news release and overview. From these, you can link to a fact sheet on the IFR.

Readable and succinct summaries are also available from CMS about the program in general, the meaningful use standards, the meaning of certified electronic health records, and the requirements for incentive funding in the Medicare and Medicaid programs. No doubt a number of summaries will appear in the coming days; two good ones to start come from the venerable blogs HisTalk and Geek Doctor.

Also released on that day was an article in the New England Journal of Medicine by the National Coordinator of ONC, Dr. David Blumenthal, that gives a succinct, big-picture overview of HITECH. Dr. Blumenthal's article makes clear that if 2009 was the planning year, then 2010 will be the implementation year. We will see the finalization of the meaningful use criteria, the launching of the regional extension centers, the start-up of a number of other programs, and the initiation of the education and training programs to ramp up the necessary workforce to make it all happen.

Another event of 2010 will be the finalization of healthcare reform legislation. I have avoided expressing my views on healthcare reform this blog (considered out of scope!), but I agree with those who say there was more "reform" and transformation of healthcare in ARRA (courtesy of HITECH) than anything that will emerge out of the legislation due to be reconciled by the House and Senate in early 2010. I do agree, however, with those who see the imperfect legislation that will emerge from that process as a "foot in the door" to more meaningful healthcare reform in the years ahead. It will not be a smooth or painless process.

So ONC has now put its proverbial cards on the table, and it is very clear how they plan to implement HITECH. There probably is not a single person in the field who agrees with everything they are doing, but it is very clear that the health IT agenda in the US will be driven by the ONC agenda. A huge natural experiment is about to take place, and I for one am excited to be a "subject" in it!

Happy New Year to all.

HIT Workforce: The ONC View

For those of us who are students of health information technology (HIT) workforce issues, the new funding opportunity announcements (FOAs) from the Office of the National Coordinator for Health Information Technology (ONC) provide an interesting glimpse into their view of the HIT workforce needed to meet the electronic health record (EHR) adoption goals of the American Recovery and Reinvestment Act (ARRA) of 2009. ONC Coordinator Dr. David Blumenthal gives a high-level vision of their approach in his blog.

In the FOAs, ONC lays out the job roles and competencies for the workforce that they believe is necessary to achieve meaningful use of EHRs. The information is spread out over the different FOAs, but I have attempted to bring it into a single narrative, which follows in this posting. The content for this posting was largely created by copy and paste from the ONC documents but I assume full responsibility for any errors introduced in my process. This is the workforce that ONC hopes to see trained with its $118 million investment in the four FOAs.

The roles are grouped into three general categories. Those with an asterisk (*) are slated to have training take place in community colleges, while those with a dagger (†) will have training occur in university-based settings. I will first list the categories and roles, and then provide more details on the roles and their competencies. (Again, to be clear, I am cutting and pasting from ONC documents, so this is not my work, but I do assume responsibility for any errors that I introduce.)

Category 1: Mobile Adoption Support Roles
These members of the workforce will support implementation at specific locations, for a period of time, and when their work is done, will move on to new locations. They might be employed by regional extension centers, vendors, or state/city public health agencies.

• Implementation support specialist*
• Practice workflow and information management redesign specialist*
• Clinician consultant*
• Implementation manager*

Category 2: Permanent Staff of Health Care Delivery and Public Health Sites

These roles are needed for ongoing support of health IT at office practices, hospitals, health centers, Long Term Care (LTC) facilities, health information exchange organizations and state and local public health agencies.

• Technical/software support staff*
• Trainer*
• Clinician/public health leader†
• Health information management and exchange specialist†
• Health information privacy and security specialist†

Category 3: Health Care and Public Health Informaticians

These individuals will be based in universities, research centers, government agencies, and research and development divisions of software companies.

• Research and development scientist†
• Programmers and software engineer†
• Health IT sub-specialist†

Now, here are the roles and their competencies in more detail.

Mobile Adoption Support Positions

These members of the workforce will support implementation at specific locations for a period of time, and when their work is done, will move on to new locations. Workers in these roles might be employed by regional extension centers, providers, vendors, or state/city public health agencies, and would work together in teams. Preparation for this set of roles will typically require six months of intense training for individuals with appropriate backgrounds

1. Practice workflow and information management redesign specialists
Workers in this role assist in reorganizing the work of a provider to take full advantage of the features of health IT in pursuit of meaningful use of health IT to improve health and care. Individuals in this role may have backgrounds in health care (for example, as a practice administrator) or in information technology, but are not licensed clinical professionals. Workers in this role will:

• Conduct user requirements analysis to facilitate workflow design
• Integrate information technology functions into workflow
• Document health information exchange needs
• Design processes and information flows that accommodate quality improvement and reporting
• Work with provider personnel to implement revised workflows
• Evaluate process workflows to validate or improve practice’s systems

2. Clinician/practitioner consultants
This role is similar to the “redesign specialist” role listed above but brings to bear the background and experience of a licensed clinical and professional or public health professional. In addition to the activities noted above, workers in this role will:

• Suggest solutions for health IT implementation problems in clinical and public health settings
• Address workflow and data collection issues from a clinical perspective, including quality measurement and improvement
• Assist in selection of vendors and software
• Advocate for users’ needs, acting as a liaison between users, IT staff, and vendors

3. Implementation support specialists
Workers in this role provide on-site user support for the period of time before and during implementation of health IT systems in clinical and public health settings. The previous background of workers in this role includes information technology or information management. Workers in this role will:

• Execute implementation project plans, by installing hardware (as needed) and configuring software to meet practice needs
• Incorporate usability principles into design and implementation
• Test the software against performance specifications
• Interact with the vendors as needed to rectify problems that occur during the deployment process

4. Implementation managers
Workers in this role provide on-site management of mobile adoption support teams for the period of time before and during implementation of health IT systems in clinical and public health settings. Workers in this role will, prior to training, have experience in health and/or IT environments as well as administrative and managerial experience. Workers in this role will:

• Apply project management and change management principles to create implementation project plans to achieve the project goals
• Interact with office/hospital personnel to ensure open communication with the support team
• Lead implementation teams consisting of workers in the roles described above
• Manage vendor relations, providing feedback to health IT vendors for product improvement

Permanent Staff of Health Care Delivery and Public Health Sites

These roles are needed for ongoing support of health IT that has been deployed in office practices, hospitals, health centers, long-term care facilities, health information exchange organizations and state and local public health agencies. Preparation for this set of roles will typically require six months of intense training for individuals with appropriate backgrounds.

5. Technical/software support staff
Workers in this role maintain systems in clinical and public health settings, including patching and upgrading of software. The previous background of workers in this role includes information technology or information management. Workers in this role will:

• Interact with end users to diagnose IT problems and implement solutions
• Document IT problems and evaluate the effectiveness of problem resolution
• Support systems security and standards

6. Trainers
Workers in this role design and deliver training programs, using adult learning principles, to employees in clinical and public health settings. The previous background of workers in this role includes experience as a health professional or health information management specialist. Experience as a trainer in from the classroom is also desired. Workers in this role will:

• Be able to use a range of health IT applications, preferably at an expert level
• Communicate both health and IT concepts as appropriate
• Assess training needs and competencies of learners
• Design lesson plans, structuring active learning experiences for users
• Track training records of the users and develop learning plans for further instruction

7. Clinician/Public Health Leader
By combining formal clinical or public health training with training in health IT, individuals in this role will be able to lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States. In the health care provider settings, this role may be currently expressed through job titles such as Chief Medical Information Officer (CMIO), Chief Nursing Informatics Officer (CNIO). In public health agencies, this role may be currently expressed through job titles such as Chief Information or Chief Informatics Officer. Training appropriate to this role will require at least one year of study leading to a university-issued certificate or master’s degree in health informatics or health IT, as a complement to the individual’s prior clinical or public health academic training.

8. Health Information Management and Exchange Specialist
Individuals in these roles support the collection, management, retrieval, exchange, and/or analysis of information in electronic form, in health care and public health organizations. We anticipate that graduates of this training would typically not enter directly into leadership or management roles.

9. Health Information Privacy and Security Specialist
Maintaining trust by ensuring the privacy and security of health information is an essential component of any successful health IT deployment. Individuals in this role would be qualified to serve as institutional/organizational information privacy or security officers.

Health Care and Public Health Informaticians

These individuals will be based in universities, research centers, government agencies, and research and development divisions of software companies.

10. Research and Development Scientist
These individuals will support efforts to create innovative models and solutions that advance the capabilities of health IT, and conduct studies on the effectiveness of health IT and its effect on health care quality. Individuals trained for these positions would also be expected to take positions as teachers in institutions of higher education including community colleges, building health IT training capacity across the nation.

11. Programmers and Software Engineer
We anticipate that these individuals will be the architects and developers of advanced health IT solutions. These individuals will be cross-trained in IT and health domains, thereby possessing a high level of familiarity with health domains to complement their technical skills in computer and information science. As such, the solutions they develop would be expected to reflect a sophisticated understanding of the problems being addressed and the special problems created by the culture, organizational context, and workflow of health care.

12. Health IT Sub-specialist
The ultimate success of health IT will require, as part of the workforce, a relatively small number of individuals whose training combines health care or public health generalist knowledge, knowledge of IT, and deep knowledge drawn from disciplines that inform health IT policy or technology. Such disciplines include ethics, economics, business, policy and planning, cognitive psychology, and industrial/systems engineering. The deep understanding of an external discipline, as it applies to health IT, will enable these individuals to complement the work of the research and development scientists described above. These individuals would be expected to find employment in research and development settings, and could serve important roles as teachers.

Section 3016: More!

The Office of the National Coordinator for Health Information Technology (ONC) has released two more funding opportunity announcements (FOAs) for HIT workforce development. These are in addition to two previous FOAs that aim to establish community college consortia and the curricula they will utilize for rapid, short-term training of the workforce.

The first new FOA (OC-HIT-10-002) is entitled, Competency Examination for Individuals Completing Non-Degree Training. This FOA continues the emphasis on community colleges, consisting of a cooperative agreement for the development of competency testing for six job roles for which short-term community college programs are being developed. A single $6 million award will be given to an institution of higher education to perform this task. The awardee will be tasked with creating a detailed “blueprint” for implementation of the program, based on the competencies for the six workforce roles and providing structure for the content of the examinations. The awardee will be expected to collaborate with community colleges and competency-based subject matter experts to provide examinations that are suitable for the community college student population and other examinees. The awardee must also work with industry and employer groups to ensure that the materials are responsive to emerging workforce needs. They will be required to administer the exams through computer-based testing centers and the cost of the award must include their free administration to the 10,000 individuals who will be trained by the community college consortia.

The second new FOA (OC-HIT-10-003) is entitled, Information Technology Professionals in Health Care: Program of Assistance for University-Based Training. The goal of this to create training grants for university-based programs to train higher-level professionals to be part of the workforce that achieves the meaningful use of HIT. This FOA addresses a concern of many that all training was going to be carried out by community colleges. However, this FOA makes it clear that there is a role for many others, including at the leadership level, to move us toward the meaningful use of electronic health records (EHRs). A total of $32 million will be allocated for 8 awards that are funded over 39 months (three academic years plus some lead-in time). The total awards will be for a maximum of $4 million for single institutions and $6 million for consortia of institutions. All four-year institutions and universities are eligible to apply.

These FOAs bring the total spending on HIT workforce development to an impressive total of $118 million:

• Community college consortia - $70 million
• Curriculum development centers - $10 million
• University-based training - $32 million
• Workforce competency assessment - $6 million

I will devote the rest of this posting to the university training FOA. Individuals trained by the programs funded through this FOA will assume more highly specialized roles and serve as leaders in supporting the meaningful use of HIT. The training will cover six workforce roles identified by ONC:

• Clinician/public health leader
• Health information management and exchange specialist
• Health information privacy and security specialist
• Research and development scientist
• Programmers and software engineer
• Health IT sub-specialist

The FOA states that the roles listed are not rigidly defined purposefully because the field is evolving. This will give programs the ability to create new and creative approaches to educating these individuals. Of note is that there is a clear role for public health positions and not just for individuals in healthcare. Applications must describe job titles and key responsibilities that the training for these roles will fill.

Priority for funding will be given to institutions that already have existing baccalaureate, certificate, or master’s degree programs. Institutions must address at least three, and preferably more up to all six, job roles. Applications will be accepted from universities that both plan to expand their existing programs as well as create new ones.

Funding will only support “new students,” defined as those not enrolled in an HIT educational program on the date that the FOA was published, which is December 17, 2009.

Programs will be funded for 39 months (3 years, 3 months), starting in 2010, to allow three cycles of academic years. The first academic year must begin with the fall term of 2010.

Two types of students will be supported:

• Type 1 – programs that can be completed in less than one year, ideally in less than 6 months, leading to a certificate or master’s degree without thesis
• Type 2 – programs that require more than one year to complete, typically a master’s degree with thesis

Programs must maintain a ratio of five Type 1 students for every Type 2 student. Priority will be given to programs that use “creative and flexible” mechanisms to expand capacity, such as distance learning and part-time enrollment.

The FOA notes that $6,500 per trainee for program development and training related expenses will be awarded for costs associated with faculty and staff salaries, program administration, program-related equipment, faculty travel necessary to successfully implement the program, and trainee child care. It also states that for all types of trainees, the grants will support (up to a fixed maximum) trainee tuition and fees. For trainees in master’s degree programs with a required thesis, funding will additionally support health insurance sponsored or required by the awardee institution and a stipend for each trainee enrolled in the program on a full-time basis. (Although the maximum amount for annual health insurance is $2000, which I note somewhat tongue-in-cheek gives us the maximum incentive to bring about health care reform and cost control as soon as possible!)

Allowable costs include (quoted from the FOA):

• Developing and revising curricula in medical/health informatics and related disciplines.
• Recruiting and retaining students to the program involved.
• Acquiring equipment necessary for student instruction, including the installation of test bed networks for student use.
• Establishing or enhancing bridge programs in the health informatics field s between community colleges and universities.
• Faculty release time to prepare for teaching in these programs.
• Professional salaries for management of the process to create the program.

Tuition and fees for both types of trainees is supported. For Type 1 trainees, up to $10,000 may be budgeted. For Type 2 trainees, up to 60% of regular tuition and fees, not to exceed $16,000 per year, may be budgeted. Type 2 trainees may also receive an annual stipend of $15,000 and annual health insurance coverage of $2,000. F&A costs of 8% of non-tuition expenses may be budgeted.

Evaluation will be consist of close monitoring of a number of milestones in the FOA related to matriculation, graduation, and employment. A mid-award review will take place after the these milestones are compiled after the 18th month of program operation.

An important part of the proposal will be the proposed strategy for the program. It must include the following (quoted from the FOA):

• The role being addressed and (for consortial programs) the name of the institution that will be home to the program.
• The overall educational goals for the program.
• Whether the applicant is proposing to establish a new program or to expand an existing one.
• The duration of the training and whether a degree or certificate will be awarded. If a degree, specify the degree and which institutional department will award it. If a certificate, specify the proposed title of the certificate and which department will award it.
• If the program is a new program, when the training program will matriculate its first trainees.
• Whether the program addresses health care, public health, or both.
• The target number of trainees to be enrolled in this program per year, and, separately, the number of these trainees to be supported by funds from this grant.
• The curriculum for the program listing titles and credit hours (or trainee time commitment) of all required courses and other required experiences. For each required course/experience, indicate whether it is currently offered or whether it will require development. Include in an appendix, a brief (approximately 200 word) description of each required course or experience.
• The faculty members who will be offering the required courses and other experiences. Biosketches for these faculty members must be included in a separate section of the application.
• Mechanisms for student mentoring and advising, also specifying how trainees’ progress through the program will be monitored and evaluated.
• If the program requires supervised research or scholarship (a terminal project, thesis, or dissertation), a description of the resources that will be available to students as venues for this work.

The four collective FOAs represent a comprehensive and well-resourced approach to growing the HIT workforce. A $118 million investment in HIT workforce is an excellent expenditure of economic recovery funds. I will have more to say in the future but for now I need to start my proposal writing!

Section 3016 Has Arrived!

The long-anticipated Funding Opportunity Announcements (FOAs) for health information technology (HIT) workforce development, as specified in Section 3016 of the American Recovery and Reinvestment Act (ARRA), have been released by the Office of the National Coordinator for Health IT (ONC). These FOAs reveal the overall plans of ONC for quickly ramping up the workforce to meet the ARRA electronic health record (EHR) adoption goals. This will be done by two specific FOAs, one that funds development of five regional consortia of community colleges around the country, who in turn will implement curricula developed by the other FOA that funds five national curriculum development centers.

ONC has also provided its own analysis and plan for the workforce. Both FOAs state a need to train 51,000 workers to implement the ARRA HIT agenda. They list specifically six job roles for this workforce, noting that preparation for any them will typically require six months of intense training for individuals with appropriate backgrounds. These individuals could work for a variety of entities, including health care organizations, regional extension centers, government organizations, vendors, and others. (It would be great for those of us with an interest in workforce research and education to see their data and analysis of the workforce needs. I hope they release it at some point.)

Four of the job roles are "mobile adoption support positions" and involve personnel who carry out the initial EHR implementation at a site and then move on to the next one. The specific roles for these positions are:

• Practice workflow and information management redesign specialists
• Clinician/practitioner consultants
• Implementation support specialists
• Implementation managers

The other two job roles are "permanent staff of healthcare delivery and public health sites" and provide ongoing support after implementation. The specific roles for these positions include:

• Technical/software support staff
• Trainers

Although this process presents a coherent and specific plan to quickly ramp up the workforce, an approach with which I concur, I also hope it also raises the visibility of clinical informatics as an important component of EHR adoption and a career option for people who aspire to work professionally (and academically) in HIT. I am somewhat disappointed that the programs developed will not have pathways that articulate with more formal degree programs (e.g., baccalaureate and master's degrees, or even associate degrees for that matter). I do hope that educators who participate will be given the option to find ways to make further articulation and career enhancement happen. In addition, while I know that community colleges have historically risen to the challenge of quickly implementing skills-based training, I also wonder whether those with no experience or expertise teaching this content will be able to ramp up quickly enough. Where, for example, will they find faculty with sufficient expertise to do more than just deliver a packaged curriculum?

One also has to wonder whether those with short-term training will have the complex array of knowledge and skills in areas like healthcare workflow, change management, quality measurement, and oral and written communication (among even more) that are so essential for successful EHR implementation in complicated entities like healthcare organizations. We will no doubt be witnessing a great workforce and education "experiment" (just like, I suppose, all of the ARRA EHR agenda). I look forward to being a "subject" in that experiment.

On to the details. The first FOA (EP-HIT-10-001) is entitled, Community College Consortia to Educate Health Information Technology Professionals in Health Care Program. This FOA divides the country into five regions, each of which will have one consortium. Each consortium has a target amount of funding, number of students, and number of institutions. (Oregon is in Region A, the smallest of the five regions in terms of population served.) The overall allocation is $70 million.

Each consortium will have a lead organization and targeted number of member community colleges (varying from 5-8 in Region A to 17-23 in Region E in the Northeast). Each will have an expected minimum number of students each year, with the overall goal of training 10,500 students annually. Programs will not award degrees, but instead award a six-month certificate. It is assumed many students will have some background in healthcare and/or IT, and will need to flexibly learn more of what they do not know. Each member institution does not have to offer training for all six job roles, but each consortium as a whole must cover all the roles. The number of institutions must be within the specified range (unless an exemption is given), though each member does not need to train an equal numbers of students. Training must be commence by September 30, 2010.

Funding is for two years. The FOA does not address sustainability, either as requiring it in the plan or its being assessed in evaluation of proposals. It does say that the funding is a one-time opportunity. Up to $1M per consortium can be budgeted for consortium expenses. Up to 8% indirect (F&A) costs will be awarded to the lead institution and any others that have federal F&A agreements. My reading of the FOA is that any institution of higher learning, including a university, that offers HIT training (e.g., OHSU) can be a lead institution. The amount of funding works out to about $3,000-$4,000 per student trained (depending on the region and how much is allocated for consortium expenses).

The second FOA (EP-HIT-10-003) is entitled, Curriculum Development Centers Program. The goal of this FOA is to develop curricula that will be deployed by the community college consortia formed in the other FOA to train HIT professionals in 20 topics the cover the six specific job roles.

This FOA will fund five centers to develop materials in some number (applicants need to specify 7-10 where they have expertise) of areas from a list of 20. They are required to be academic training programs in informatics, HIT, or HIM, and engage both community college educators as well as instructional design experts. One center will also be designated the National Training and Dissemination Center, and additionally carry out training as well as establishing the repository for download of materials.

Each center will be funded up to $1.82M over two years ($910,000 per year), including indirect costs. The National Training and Dissemination Center will receive an additional $900,000 ($450,000 per year), including indirect costs.

Like the other FOA, there is a great amount of prescriptive detail provided. The 20 curricular areas from which to choose include:

• Introduction to Health Care and Public Health in the U.S
• The Culture of Health Care
• Terminology in Health Care and Public Health Settings
• Introduction to Information and Computer Science
• History of Health Information Technology in the U.S.
• Health Management Information Systems
• Working with Health IT Systems
• Installation and Maintenance of Health IT systems
• Networking and Health Information Exchange
• Fundamentals of Health Workflow Process Analysis & Redesign
• Configuring EHRs
• Quality Improvement
• Public Health IT
• Special Topics Course on Vendor-Specific Systems
• Usability and Human Factors
• Professionalism/Customer Service in the Health Environment
• Working in Teams
• Planning, Management and Leadership for Health IT
• Introduction to Project Management
• Training and Instructional Design

This whole approach is not without risk, but as I said above, it is a great plan for quickly ramping up the workforce. I do hope that it will allow for professional growth and development for those undertake the training and want to work as professionals in this extremely important component of improving healthcare. I also hope that the process will be evaluated well, so we can make corrections to the process when we find areas it does not work. In any case, I will stop writing now and get back to working on my proposals!

Two new international workforce studies

Things are really heating up in the health information technology (HIT) workforce arena! Not only have two new workforce analyses from abroad been published, but in the US, the long-anticipated Funding Opportunity Announcements (FOAs) for HIT workforce development, as specified in Section 3016 of the American Recovery and Reinvestment Act (ARRA), have been released by the Office of the National Coordinator for Health IT (ONC).

The first workforce study comes from Australia (Legg, M. and Lovelock, B., 2009. A Review of the Australian Health Informatics Workforce. Melbourne, Australia: Health Informatics Society of Australia). Commissioned by the Health Informatics Society of Australia (HISA), this analysis looked at the "health informatics" workforce in that country. The authors defined health informatics for the purposes of its analysis, although also noted that this definition was likely incomplete. The study was carried out in two steps consisting of two focused workshops with a small number of people and then a larger survey that was distributed to all members and anyone who ever participated in any HISA activity. A total of 1,279 (out of 6,434 possible) people completed the latter.

The study classified jobs into two broad categories:

1. Those who work "in the system," e.g., to use their words: records, analysis, direct, decision, communications, and training
2. Those who work "on the system," e.g., to use their words: systems, infostructure, improvement, education, resource, and administration

The study characterized the work of these individuals by categories (many performed more than one) and also captured data on perceived needs for education, training, and expansion of the workforce. The authors concluded with a number of recommendations for expansion and improvement of the workforce.

On the issue of workforce size, the authors made several estimates, all of which came out with a relatively consistent range. This included the use of government employment statistics for health information management and IT professionals in health care. The authors also made a quick calculation based on my own previous research (of other research studies) finding a ratio of 1 IT worker per 50 non-IT workers in healthcare settings. The bottom line is an estimate of around 12,000 health informatics professionals (range 9,000-15,000) in a country with a population of approximately 21 million. (This number is not that far off the proportionate number of people identified for the United States in my HIMSS Analytics Database study, i.e., 108,390 IT personnel, perhaps along with 10,000 informaticians and 50,000 need for the ARRA EHR agenda, in a country of over 300 million.)

The study also reported that participants consistently expressed concern about a pending shortage of personnel, for which the authors proposed a number of solutions. These included efforts to increase the supply of workers through training and re-training, improving their productivity, and reducing demand through better design of systems and processes.

The second workforce study comes from Canada (O'Grady, J., 2009. Health Informatics and Health Information Management: Human Resources Report. Toronto, Ontario, Prism Economics and Analysis). It focused on professionals defined as working in the fields of health informatics and health information management . This study attempted to characterize job roles and activities, quantify the workforce, and anticipate future needs based on low, medium, and high growth scenarios. (They also noted that Canada was similar to the US and different from most Western European countries in being a laggard in the adoption of HIT.) Similar to other studies, they used a variety of techniques, including government employment statistics. They calculated needs based not only on growth in use of HIT but also replacement of those retiring or otherwise leaving the workforce.

The study looked at seven categories of workers, assessing job roles and specific challenges for each. In aggregate, the authors estimated current HIT employment in Canada at 32,450, broken down among the job categories as follows (approximately):

1. Information Technology - public sector 11,000-13,000, private sector 5,000-6,000
2. Health Information Management - 4,300-5,800
3. Canadian Health System Management and Administration (counted in Analysis and Evaluation)
4. Project Management - public sector 760-900, private sector 1,100-1,300
5. Organizational and Behavioral Management - public sector 1,100-1,300, private sector 1,900-2,300
6. Analysis and Evaluation - 3,300-3,900
7. Clinical Informatics - public sector 600-710, private sector 380-450

The growth scenarios were based on the following (interesting) assumptions:

• Low growth - across the board expenditure cuts by the Canadian health system
• Medium growth - deferring of some capital investments
• High growth - HIT investment unaffected by changes in health care spending

The cumulative employment growth for all categories combined to 2014 would then be:

• Low growth - 7.6% growth to 35,020
• Medium growth - 14.3% growth to 37,200
• High growth - 26.1% growth to 41,030

For a country with a population of 33 million, these numbers are similarly proportionate to the Australian and US data!

The study also noted that Canada, like most countries, will face a substantial training need for many current and future personnel. Not only does 27% of the current 2009 workforce require additional formal training and experience, but 39%, 59%, or 78% of the 2014 workforce will require additional training under the low, medium, and high growth scenarios respectively.

So clearly Australia and Canada have major HIT training needs. Of course, so does the United States, as noted by my HIMSS Analytics Database study as well as recent estimates by ONC. To that end, two FOAs were recently released by the ONC to address workforce needs, as specified by Section 3016. These will be addressed in another posting soon.

What is the optimal "pre-informatics" education?

Readers of this blog and other writings of mine know that I have written a great deal about the optimal education and training needed to attain the knowledge and skills to work in the biomedical and health informatics profession. However, I am increasingly asked by people what is the best education and background to have before commencing informatics education. In other words, what is the most appropriate "pre-informatics" education?

Unfortunately, this is probably not a question that has a single answer, due to the heterogeneous nature of the jobs carried out by people educated in informatics and their equally heterogeneous backgrounds going in. While many in education leadership these days talk of "career pathways," the reality is that there are many pathways that feed into informatics as well as many pathways out into a variety of jobs (as demonstrated in Figure 3 of my "A stimulus to define informatics and health information technology" paper)

It is also important to remember that biomedical and health informatics is not just the intersection of healthcare and information technology (IT). Rather, it is the unique synergy and interaction that takes place when those and other disciplines intersect. I have made this point in other postings in this blog and others.

As such, you cannot be optimally trained in informatics just by having a background in its constituent disciplines. (This is one reason why I have trouble with educational institutions that are quickly creating informatics programs merely by combining, for example, healthcare and IT courses, as noted in the above Healthcare Informatics posting.)

But let's try to develop some notion of what advice we might give to someone considering education in biomedical and health informatics. My discussion is predicated on my view (bias?) that informatics is best taught at the graduate level, where one brings together a variety of competencies into a final common pathway. Therefore, one should likely have a baccalaureate degree in one of the areas I describe next, although we have seen plenty of examples in our program of those with prior degrees in completely different fields, such as law and economics.

Clearly first and foremost on the list of advice is having some knowledge or a prior degree in the underlying biomedical or health domain of one's interest. In the case of clinical informatics, this is an understanding of healthcare and its knowledge, way of thinking, and workflow. One does not necessarily need to have a formal healthcare degree (e.g., medicine, nursing, pharmacy, etc.), but there is a clear advantage to having one.

In the case of other areas of biomedical and health informatics, analogous reasoning applies. In bioinformatics, for example, one should have a strong background or prior degree in biology and/or other life sciences. In public health informatics, one needs a substantial background or prior degree in public health or a related area.

Since informatics is often (incorrectly, in my view) equated as IT or computer science (CS) in health care or biology, the next question is, how much of an IT or CS background is required? The answer to this question is that it depends on the career pathway desired. Clearly everyone in biomedical and health informatics needs to be facile and competent with IT. They must have an aptitude for quick learning of IT systems, i.e., be a power user of computers, especially in areas like productivity applications, searching, Web applications, and the like. They must also understand "information," and have skills in its application to further goals of healthcare, biomedical research, public health, and the like.

Beyond that, the amount of IT or CS knowledge depends on one's career goals. Certainly someone who wishes to engage in tasks such as data mining, text mining, and computational biology must have a deeper knowledge. These individuals must know how to program, understand information and system architecture, and be able to adapt to new technologies as they emerge to solve specific tasks. But if someone's focus is going to be leading an electronic health record (EHR) implementation in a healthcare organization or helping healthcare teams analyze data for quality, a deep understanding of IT and CS is less necessary.

Related to IT and CS is mathematics. Again, the amount necessary depends on one's career objectives. I personally believe that every "knowledge worker" in the world should have a basic understanding of statistics. This is not just the various statistical tests and when they are appropriately applied, but also the foundational knowledge of descriptive and inferential statistics. This is not just a requirement for being a good informatics professional, but also a good citizen, and appropriately understanding research results, risk analysis, and other important issues of the world. Certainly anyone who is going to do any kind of analysis of data in their informatics work needs to have a basic knowledge of statistics.

Another set of skills that are important for many informaticians to have are business skills, soft skills, and other abilities to work with people to achieve organizational and/or project goals. Perhaps the person coding bioinformatics algorithms or data mining routines might not need much of these (though good project management skills never hurt anyone!), it is more the individuals involved in management and leadership of IT in biomedical and health settings who need these skills.

Some informaticians need other specific backgrounds and skills. For example, anyone who is going to become a researcher needs education not only in the specific research methods they hope to apply, but also exposure to larger aspects of critical thinking, study design, and related topics.

So my advice to those seeking to develop or further their careers in biomedical and health informatics through education is to have a general sense of your career direction, bring as much as the above pre-requisites as you can into the educational program, and then be prepared to learn about the rest while bringing them all synergistically together to be the best informatician you can be. While a previous degree in one of the foundational areas of informatics is helpful, it is not an absolute requirement.

Academia = Education AND Research

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

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

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

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

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

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

The workforce for meaningful use

The discussion about health IT workforce continues to heat up as health care organizations realize that achieving meaningful use of electronic health records will require not only hardware and software, but people who have the expertise to make it happen. That expertise requires as much an understanding of information use and analysis, clinical organization and workflow, and business and management as it does IT, i.e., the substance of informatics.

One recent article describes a developing "war on talent" for health IT workers. The same publication features another article about how health care organizations are "racing" to fill CIO positions.

Finally, an IT publication describes why "your next job may be in health care."

By the way, many people ask me where they can read a succinct overview about "meaningful use," and I have found a nice 6-pager by David Classen of CSC. Of course, the "ground truth" comes from the matrix recommended by the Office of the National Coordinator to CMS, who will set the final rules in the near future.

Informatics Is Not Just For Clinicians

I receive a steady stream of emails from people who are interested in careers and/or education in the biomedical and health informatics field. To the extent I can, I try to reply, giving advice and steering them to more information.

One inquiry I recently received was from someone who has an information technology (IT) background and noted that most of my writings seem to imply that informatics is a profession mainly for those with clinical or other healthcare backgrounds. He noted that I point to research and other observations that clearly show than an understanding of the clinical environment, its thinking, and its workflows are essential for career success in this field.

This individual asked, is there a role for non-clinicians in this field? My reply, as always, was a definite YES! Not only has our workforce research and the experience of others shown that there are plenty of opportunities for work for those who do not have clinical backgrounds, we also know that many of the 250+ alumni of our graduate program, a number of whom are non-clinicians, are gainfully employed.

This is not the first time I had been asked this question. In fact, we felt compelled to write about it several years ago in an issue of our department newsletter, noting even then that were plenty of jobs for non-clinicians in a variety of informatics settings.

However, it is clear that those without healthcare backgrounds must understand clinical environments. They need to understand its operations, it workflows, and even its thinking. But that can be learned, and for many jobs it is sufficient to not have formal training in a healthcare profession.

Now it is true that non-clinicians might end up in different jobs and follow different career paths than clinicians. Of course, that is the case even among the different types of clinicians. The best example of that is the position of Chief Medical Information Officer. This position is almost always filled by a physician. However, there are many other informatics jobs in healthcare settings that other physicians, other healthcare professionals (e.g., nurses, pharmacists, lab techs, healthcare administrators, etc.), and non-clinicians fill.

Some readers of this blog have seen my figure that provides an analogy from Bayesian statistics, i.e., what you do in a career after an informatics education is a function of both what you brought into the education and of what knowledge and skills you gained in the education. Ok, so the analogy is not perfect, but I hope it makes the point that informatics is a large and diverse field, and there are roles for people of many backgrounds who are passionate about using information to improve health.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Informatics: A Field and Profession Coming Into its Own

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

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

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

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

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

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

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

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

Informatics Education: A Final Common Pathway

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

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

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

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

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

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

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

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