Update on the ONC Health IT Curriculum Project

It has been a while since I provided an update of the Office of the National Coordinator for Health Information Technology (ONC) Health IT Curriculum Project. I had the opportunity to give a presentation about the curriculum at this week's HIMSS Conference, so will use the preparation for that to give an update here.

The major news from the project is that the third version of the curriculum will be released in the next month. Version 3 will have the same component names and structure, but the content has been substantially revised and improved. In addition, there will be much more consistency of the slide formats as well as file content and naming. The content itself has been revised based on feedback obtained by a variety of mechanisms, including contracting with the American Medical Informatics Association (AMIA) and expertise they garnered in a process last summer. The materials also have improved accessibility for those with disabilities.

Some have expressed some concern that the project "ends" on April 2, 2012. While it is true that the ONC grant ends on that date, the Web site will continue to be available beyond then. ONC is also considering a no-cost extension of the grants. Stay tuned for more details.

As with Version 2, the Version 3 materials will be made available to the general public. Anyone will be able to go to the Web site of the National Training & Dissemination Center (NTDC) Web site and create a login to enable downloading of the materials.

Other news includes a mention of the curriculum as one of the major accomplishments of ONC for 2011, according to the National Coordinator, Dr. Farzad Mostashsari.

Another useful accomplishment was the addition of a search capability to the NTDC Web site. The search engine allows searching over all text-containing documents. The search engine output allows list the files containing the search terms and allows downloading of the individual file or the unit .zip file that contains the file. The search engine indexed the 1342 Word documents and 460 Powerpoint files and has made them available for word-based searching. (For language trivia buffs, there are 37,485 unique words in these files.)

Additional news about the project includes data about the size of the Version 2 materials as well as download data since its release, including public users.

The entire collection of materials, including the slides, voice-over narration of the slides, and other materials, is 7.84 gigabytes in size. There are a total of 33,172 files. This actually does not include the VA VistA for Education electronic health record system, which has an installer file that is another 770 megabytes in size. VistA requires a license for the Intersystems Cache system, which is freely available to academic institutions but not others. The narration of the slides, available as both Flash-based "video" as well as MP3 audio files, totals 125.6 hours. As noted above, the materials have 1342 Word documents and 460 Powerpoint files. The latter contain a total of 8913 slides.

We also have details about the downloading of Version 2, covering the period from the public rollout to the end of 2011, about one-half year. Before delving into detail about the downloads, it is important to remember the structure and contents of the curriculum. The curriculum consists of 20 components, each aiming to be comparable in size to a three-credit college course. These courses are part of the various workforce roles around which the ONC community college workforce development program is organized, but of course can be used independently either as a whole course or even broken into parts. Each component is broken down into 8-12 units. Each unit contains voice-over-Powerpoint lectures (with transcripts), self-assessment quizzes, and other learning activities (such as discussions and hands-on exercises).

The NTDC web site is structured for downloading by units. The workforce for someone downloading is to create a login (or, in the case of community college faculty users, have a login created, which allows access to additional curricular support) and then navigate through the components to the individual units (packaged in .zip files) for downloading. (We do plan to implement the ability to download entire components in 2012.) Also available for downloading is .zip file containing all the component blueprints (syllabus-like documents) as well as the installer and a help file for VistA for Education.

All told, there were 284,398 downloads of Version 2 units and other files between May-June and the end of 2011. It is important to put this large number in context, which it represents the number of items downloaded. These downloads were carried out by 537 community college faculty and 4680 public users. The public users came from 31 different countries, although the vast majority were from the US. Many of the registering public users did not provide the information the system asked when creating the login, so their background and demographics are not accurately characterized, but browsing of the log shows many educators as well as individuals connected to health care organizations.

The components with the largest number of downloads were Components 3 (22,645), 5 (19,504), and 1 (18,920). The average number of unit downloads per component varied from 2102 for Component 1 to 931 for Component 13. The component blueprints file and VistA for Education installer were downloaded 3255 and 3136 times respectively.

Additional insight can be gained from looking at the minimum and maximum amount of downloads of units within each component. This provides a sense of how many users are downloading one or more units within a component. The minimum number of units downloaded within a component tend to be much closer across the components than the total number of downloads or the maximum. For example, one of the units of Component 5 was only downloaded 925 times, which was not much more than the most minimally downloaded unit of Component 20 (923). This implies that there might be two downloader types: those who take everything for a given component and those who pick and choose.

All told, we are pleased that the ONC Health IT Curriculum has become a substantial global resource. It will be improved with Version 3 that is coming shortly. We are also exploring ways to sustain it beyond the end of the HITECH funding.

eHealth Initiative Report on Hiring in Health Information Exchanges

The eHealth Initiative (eHI), a health information exchange (HIE) advocacy group, recently released a report stating that while HIEs are likely to generate jobs in health information technology (HIT), few of those jobs have gone to those trained by the workforce development programs of the Office of the National Coordinator for Health Information Technology (ONC). As one who is associated with the ONC workforce development programs, I was naturally alerted to the report as well as an article in the trade publication, Health Data Management.

My overall reaction to the eHI report is that while I do not disagree what its findings and conclusions, I do believe those findings and conclusions need to be viewed as part of a larger perspective about HIE and HIT employment. I also believe that the reporting of the methodology used for the report is incomplete, leading to some uncertainty about the meaning of its findings and conclusions. In particular, I wonder whether the report authors or those surveyed fully understand the ONC workforce program or even the HIT workforce itself. There may be more information about this report in one of eHI's proprietary publications, but I cannot find anything on their Web site. (Although I support the work of eHI, I am not a member.)

I do acknowledge up front that I have a vested interest in the ONC workforce development program. I am funded on two grants, one devoted to curriculum development for the six-month community college programs and another for university-based training in the Oregon Health & Science University (OHSU) graduate program in biomedical informatics. I also believe it is fair for anyone to question the value of these programs and whether the investment being made is productive.

My main problem with the report is that its methodology is incompletely described. To begin with, the report itself has no listed author(s) or contact information. Who carried out this report and how can they be contacted?

A related concern is whether those who developed the report's survey or those who answered it are sufficiently knowledgeable about the ONC workforce program itself.  The report does not describe how the question(s) about the ONC programs was/were asked or how knowledgeable the respondents were about the different programs. Many people, for example, are unaware that the program is larger than just the six-month community college certificate programs. Are they knowledgeable, for example, of the university-based training (UBT) programs, which have a workforce role called "Health Informatics Management & Exchange Specialist" that is likely to be most amenable to work in HIEs? This workforce role has been the most subscribed workforce role among the six covered by the UBT programs.

By the same token, the report does not put employment within HIEs in perspective. While I certainly believe that HIEs are a critical element to the larger success of HIT adoption, it is important to remember that the number of people employed in HIEs will be a relatively small part of the overall HIT workforce. For any given state or region, there are many healthcare organizations whose HIT systems will feed into one or a small numbers of HIEs. Although there will be many important jobs for those who implement, lead, and utilize HIEs, their numbers will be modest relative to the large number of HIT professionals in hospitals, physician offices, and other health-related organizations. It is just simple math.

Also important to remember is that many HIEs are still early in development, where the critical skills are more around planning and development than implementation. It is not surprising to see consultants being heavily used, as opposed to professionals just out of their education programs without a great deal of workforce experience. Related to this, the report seems to look only at direct hiring of ONC workforce program graduates by HIEs. We do not know how many graduates of ONC programs work for consultants, vendors, or others as opposed to being hired directly by HIEs, on which the report seems to focus

We also need to remember that HIE jobs vary in the same way that HIT and clinical informatics jobs do. As such, those trained in the ONC programs might not be a fit for the jobs available in HIE. In fact, it is likely that HIE jobs require a great deal of HIT workforce experience, which ONC workforce program graduates by definition do not have.

The Health Data Management article also goes off on a tangent and raises some issues about the ONC HIT curriculum. Some of these are valid criticisms, but it is also important to remember that these curricular materials are designed for HIT teachers, who are encouraged to use them creatively to offer a meaningful learning experience and not just a rote curriculum out of the box. Some of the community colleges have done this better than others in this regard.

While I applaud eHI for brining the workforce issue in the context of HIE to light, I also believe that their report raises more questions than it answers. I do hope that someone will come forth and explain the details of the report's methodology and its findings. I will certainly make a postscript to this entry in my blog if anyone does so. I also encourage dialogue about the value of the ONC workforce programs and how we can improve them not only for content, but also the employability of their graduates.

Is Medicine an Information Science? Perspective from Physician Time Studies

We tend to think of medicine as a health science or a life science, yet in many ways it is an information science, and may be becoming more so with the growth of data generated in the care of patients. If medicine is indeed an information science, then there is a critical role for  biomedical and health informatics, which is the field that uses information to improve some aspect of health, healthcare, and biomedical research.

A couple years ago I reviewed in this blog  two articles that had recently been published about the role of information in medicine. One article, by Stead et al. posited that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains" [1]. The authors noted that the numbers of facts per clinical decision will likely increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.). The second article, by Shortliffe, was published about the same time in a special issue of JAMA devoted to medical education [2]. He noted that while medical education (rightly so) goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort to obtaining, using, and analyzing another critical component of medical care, namely information.

What evidence is there that medicine is an information science? After all, most modern knowledge workers - i.e, professionals in financial analysis, aviation, and  marketing to name a few - make critical use of information in their work too. A number of studies have looked at how physicians spend their time, and provide clear evidence that information is critically important to their work. Some might think that physicians spend the majority of their time with patients, such as examining them or performing procedures on them. However, these time studies show that physicians spend more time interacting with information, such as reviewing data and documenting patient care, than interacting directly with patients.

These studies assess the tasks of physician work and the time spent doing them. Some of the tasks primarily involve using information. (It  is unfortunate that others in the healthcare environment have not been studies, but as often happens, physicians are the targets whom researchers have chosen to study.) Enough of these studies have been done to lead Tipping and colleagues to perform a systematic review [3]. In addition, four more studies have been done since the completion of the systematic review by Kim et al [4], Tipping et al. [5], Yousefi [6], and Chisholm et al. [7].

The systematic review points out that the studies are heterogeneous and cannot be group to do something like a meta-analysis. Yet the results are surprisingly consistent. The systematic review develops a classification to which most studies relatively adhere. The studies all measure in some manner "direct" patient care, where the physician interacts directly with the patient. They likewise describe "indirect care" of the patient, where the physician reviews patient data, performs documentation, and communicates with various people, such as members of the care team, the patient and/or their family, insurance companies, and others. Finally, most studies have some sort of "other" category that includes travel (either within a healthcare facility or between them), education, and personal time (such as eating). The systematic review and three of the follow-up studies focused physicians who work on hospital wards (i.e., hospitalists), although one of the more recent studies looked at emergency department physicians [7]. The studies have been somewhat though not exclusively weighted toward academic facilities and physicians in training.

Even with the variation in definition of the categories and tasks within them, the results are remarkably consistent. While the range is wide, most of the studies show that physicians spend about 15-17% of their time in direct patient care. Conversely, they spend about 64-67% of their time in indirect patient care, often relatively evenly divided between reviewing results, performing documentation, and engaging in communication. The tasks of reviewing results and carrying out documentation are clearly information-focused in nature, which means that physicians spend about 35-40% of their time engaged with information. One could also probably argue that aspects of direct patient care are information-focused as well, as the physician is gathering information about the patient. The education component of the other category is of course very information-oriented.

Some additional interesting tidbits come of the individual studies. The newer Tipping et al. study took place in a setting of full electronic health record (EHR) implementation and noted 34% of physician time was spent interacting with the EHR [4]. This study and two others by O'Leary et al. [8] and Westbrook et al. [9] in the Tripping et al. systematic review looked at multitasking, finding it was being done during 16-21% of physician work time. O'Leary et al. also found physicians received 3-4 pages per hour [8], while Westbrook et al. noted an average of 2.9 interruptions per hour [9]. Kim et al. found that the amount of direct care was higher at the beginning of shifts while indirect care was higher toward the end of shifts [5]. They also noted that 7% of physician time was spent in travel within the healthcare facility, wondering whether this might be an area where efficiency of work can be improved [5].

In their study of emergency department physicians, Chisholm et al. noted that somewhat more time was spent in direct patient care (31% for academic settings and 38% for community settings) and less in indirect care (55% for academic settings and 50% for community settings) [7]. They also found these emergency physicians were interrupted on the order of 10 times per hour.

These studies collectively show that physicians in hospitals and in emergency departments spend a substantial amount of their time interacting with information. Going forward, the amount and complexity of information is likely to increase. It will come from diverse sources, such as patients entering data into their personal health record (PHR), clinical data coming being provided via health information exchange (HIE), and the growing amount of data from genomics and related areas. This makes the science of biomedical and health informatics even more critical to the medical field.

References

1. Stead, W., Searle, J., et al. (2010). Biomedical informatics: changing what physicians need to know and how they learn. Academic Medicine, 86: 429-434.
2. Shortliffe, E. (2010). Biomedical informatics in the education of physicians. Journal of the American Medical Association, 304: 1227-1228.
3. Tipping, M., Forth, V., et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine, 5: 353-359.
4. Tipping, M., Forth, V., et al. (2010). Where did the day go?--a time-motion study of hospitalists. Journal of Hospital Medicine, 5: 323-328.
5. Kim, C., Lovejoy, W., et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine, 5: 329-334.
6. Yousefi, V. (2011). How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management, 18: 159-164.
7. Chisholm, C., Weaver, C., et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine, 18: 117-122.
8. O'Leary, K., Liebovitz, D., et al. (2006). How hospitalists spend their time: insights on efficiency and safety. Journal of Hospital Medicine, 1: 88-93.
9. Westbrook, J., Ampt, A., et al. (2008). All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Medical Journal of Australia, 188: 506-509.

One Patient's View of the Optimal Personal Health Record

In teaching current and future informatics professionals, I often speak about the Internet-savvy baby boomers who will interact more with the healthcare system as they get older, which will likely usher in the era of patient-centered informatics more than anything heretofore. I recently had some activities in this role, which gave me some firsthand thoughts about the personal health record (PHR) and interacting with the healthcare system through the PHR and other Web-based means.

There are many views about the role of the PHR and how it should be optimally used. Should it, for example, be primarily connected (sometimes called tethered) to the electronic health record (EHR) of the organization where one receives most or all of their care. While few people desire a truly standalone PHR (i.e., not connected to any data), some advocate it is more important that we move toward an integrated PHR that can interact with data from many sources, from one's own healthcare system to health-related data they capture, such as diet and exercise logs [1, 2].

I recently had the opportunity to interact with my healthcare provider system (OHSU) and its PHR offering (MyChart, tethered to its Epic EHR system). I am fortunate to be in good enough health to not be a major consumer of OHSU healthcare services, but in these interactions, I did come to realize that I want my healthcare system to provide the same kinds of online services that I routinely use for banking, travel, and consumer purchases (e.g., books, electronics, music, etc.). In this regard, OHSU, like many healthcare organizations, falls short.

My experience showed me that what I really want is not so much a PHR (thought it is part of the mix), but rather the ability to manage my data and information with a PHR as well as the ability to carry out all of my interactions with the healthcare system. This includes everything from appointment scheduling and prescription refills to tracking my personal health.

What led to this interaction was what turned out to be a spurious slightly elevated fasting blood sugar. Although I am not overweight, I do have a family history of Type II diabetes, so this is something important to monitor. I also have a number of other cardiac risk factors, including some that are not modifiable (family history), which I try to mitigate with healthy living, namely diet and exercise.

(My cardiac family history is like a roulette table. I have a maternal grandmother and her father who lived to over 100. My maternal grandfather, on the other hand, died of coronary heart disease in his early 50s. Likewise, my maternal grandparents had diabetes and heart disease but lived into their 80s. My father had coronary bypass surgery just before age 50 but is alive and has been symptom-free over 30 years later. Both my maternal grandfather and my father would likely have their coronary heart diseases treated differently in the modern era, with our present array of medications and procedures such as angioplasty. I note that I am also different from them in that they were both smokers. The question is whose genes for coronary disease I have inherited, which is perhaps something our bioinformatics colleagues will be able to answer in the future.)

I also have mild hypertension and a mixed lipid panel, with normal total cholesterol but a sometimes low HDL. In the process of checking a lipid panel, my physician also ordered a metabolic panel, which included a blood glucose. I have always had a fasting glucose at the high end of normal at around 100.

In MyChart, results are released to patients after being reviewed by the provider. This is probably a good idea, although for more routine things, it might not be, since it delays the patient (including knowledgeable ones like me) from getting their results. My initial glucose (along with my lipid profile, which was originally my main concern in getting the blood drawn) was released within hours of the blood being drawn. I was not so lucky for the follow-up tests.

I was impressed to get an email notification within a few hours after the blood was drawn for the first set of tests directing me to MyChart, where my results and a brief message from my physician were waiting. The results showed a fasting blood sugar of 107, which is classified nowadays as "prediabetes." My physician suggested the next step should be to wait and check it again in three months. However, given my family history and other cardiac risk factors, I wanted to know more. In particular, I wanted to know what a two-hour postprandial glucose and a hemoglobin A1C level would show.

My personal physician is also a professional colleague at OHSU and someone I have known since I arrived there 21 years ago. I chose to contact him through the MyChart messaging functionality, although did not get a reply. So I sent him a regular email, to which he responded promptly and ordered the additional tests. I do know that some physicians have trouble keeping up with the stream of email that comes in via MyChart. I do not blame them as much as I blame our healthcare system that only pays for face-to-face medical encounters  and not overall care of the patient, although perhaps that will change with accountable care organizations (ACOs) [3].

I had the second set of tests done on a Friday morning and was hoping for the same quick turnaround as my other tests. This time, that did not happen, and I did not hear back from my physician until late the following Monday. The time lag was certainly not critical for my health, but I did have a desire to learn the results as quickly as possible. I did receive excellent news. Not only was the fasting glucose 97 this time, but my postprandial glucose was 80 and my hemoglobin A1C was 5.1. Not even a hint of diabetes!

Another encounter with the OHSU health system having nothing to do with MyChart but related to electronic interaction with the health system happened about this same time. As noted above, I also have mild hypertension, which is easily controlled with 10 mg of amlodipine daily (and no doubt my healthy diet and dedicated exercise regimen). I get refills for my amlodipine using the OHSU Mail Order Pharmacy. I can request a refill by sending an email to an address on their web site.  There are several problems with this approach. One is that getting my refill in a timely manner is dependent not only on my remembering to send an email a week or so before I run out, but also the timely processing of my request by the pharmacy, which does not always seem to happen. A modern PHR connected to my health system would send a reminder at the appropriate time that let me order the renewal with a click or two.

Another PHR-related activity with my blood pressure comes from the recent home blood pressure monitoring machine I purchased. I am impressed that it stores my results and, when I connect it to a USB port of my computer, uploads the data to my account in Microsoft HealthVault. Of course, it would be more ideal if this data were integrated with my MyChart account, but that does not yet happen. Speaking of HealthVault, I have to say that although I am not always a big fan of Microsoft software or their business practices, they did get it right with HealthVault. It makes sense to have built a PHR platform rather just an application. I could see in the long run how secure cloud-based storage of all our data, even that in the EHR, would be optimal. (Of course, security and availability would need to be rock-solid.)

As mentioned above, I do try to mitigate my cardiac risk factors with diet and exercise. My diet mostly follows the advice of Michael Pollan, "Eat [real] food, mostly plants, not too much" [3]. My exercise consists of running three days a week and cross-training with weights two days a week. I actually pursue this lifestyle less for future benefits and more for the present, as it gives me more energy and makes me feel better here and now. Any later-life benefits will be a plus. I do track my exercise and weight in a spreadsheet but have never felt compelled to take the time to collect any more detail or enter it online.

All of these experiences made it clear to me that what I want most in my online patient experience is not just a PHR, but rather the ability to manage my data integrated with my interactions with all of my healthcare providers. In addition, I want to be able to handle routine transactions in a modern eCommerce-like manner, such as making appointments and ordering prescription refills online. Some may argue that there is not a business case for healthcare organizations to act this way, since our current healthcare system pays clinicians for doing things and not for providing comprehensive, integrated care. I hope, however, that this is not the future, and that healthcare organizations like OHSU will need to serve its customers online because its Internet-savvy baby boomer customers will come to expect it and might seek care elsewhere if they do not get it.

References

1. Detmer, D., Bloomrosen, M., et al. (2008). Integrated personal health records: transformative tools for consumer-centric care. BMC Medical Informatics & Decision Making, 8: 45.
2. Tang, P. and Lee, T. (2009). Your doctor's office or the Internet? Two paths to personal health records. New England Journal of Medicine, 360: 1276-1278.
3. Fisher, E., McClellan, M., et al. (2009). Fostering accountable health care: moving forward in Medicare. Health Affairs, 28: w219-w231.
4. Pollan, M. (2009). In Defense of Food: An Eater's Manifesto. New York, NY. Penguin.

OHSU Biomedical Informatics Education: By the Numbers

This year, 2012, marks the 17th year of the Oregon Health & Science University (OHSU) Biomedical Informatics Graduate Program. What began with a half-dozen Master of Science (MS) students has grown to one of the largest programs in the country, featuring certificates and degrees, three tracks, and a large distance learning component. While informatics education actually started in 1992 with the awarding of our first National Library of Medicine (NLM) Fellowship Training Grant, we did not launch any degree program until 1996.

Now, 17 years later, the program has awarded 401 degrees and certificates to 378 people. Another 19 have completed the NLM Fellowship program without obtaining a degree, bringing the total of alumni to 397 individuals. These alumni are highly successful by any measure, having taken jobs in industry, academia, healthcare organizations, and other settings. Some have gone on to become successful faculty in the field while many more have gone on to take operational informatics roles in companies, healthcare institutions, governments, and other organizations.

The entire number of individuals who have enrolled in any of our graduate programs since its inception  is 1297. The largest enrollment has been in the Graduate Certificate Program, with 974 enrollees. The total enrollment in the other programs has been 27 PhD, 217 MS, and 240 Master of Biomedical Informatics (MBI). The total number of students in all programs adds up to more than the total number of students because some have taken advantage of the "building block" structure of the program that allows students who are enrolled at one level to carry courses forward to a higher level (subject to time limitations).

The most common instance of advancing from one program to a higher level is moving from the Graduate Certificate to one of the master's degree programs. This has been done by 118 students, 41 of whom have completed the master's degree. Three individuals have advanced from the Graduate Certificate to the PhD (two being master's students along the way), while 15 out of the 27 students who have even been in the PhD program were in a master's program at some point.

The breakdown of degree and certificate graduates of the program is 11 PhD, 66 MS, 88 MBI (also including a half-dozen who completed the degree when it was called Master of Medical Informatics) and 236 Graduate Certificate. While it may seem that the program has a somewhat low graduation rate, it must be remembered that people enroll in graduate programs for reasons other than obtaining a degree or certificate. A not insignificant number of our students are already highly accomplished academically and choose a more "a la carte" path to furthering their education than obtaining a degree or certificate. Another reason for a seemingly low rate of graduation is that the program has witnessed substantial growth in recent years, meaning that many students in the program are still current students.

Students in the program have always come from a diversity of backgrounds and many bring substantial prior achievement into the program. More complete data about student backgrounds is available for those who enrolled in the program since 2007, when OHSU started doing a better job of capturing such data.

Of the 819 individuals who have enrolled in the program in 2007 or later, a total of 215 (26.3%) have prior master's degrees, 56 (6.8%) have non-medical doctoral degrees, and 211 (25.8%) have medical degrees. The most common types of master's degrees include MS (82), MBA (40), and MPH (27). The program has 26 (3.2%) individuals with explicit nursing degrees, although we know there are some other nurses who do have "nursing" explicitly in their degree titles.

Another group into which to drill down further is physicians, especially in light of the newly designated subspecialty of clinical informatics and the possibility of altered pathways for training in the future (i.e., clinical fellowships). Our physician enrollment since 2007 includes 184 MD, 15 MBBS, and 12 DO over the course of the program, with 78 MD, 6 MBBS, and 1 DO graduating. These numbers represent 25.8% of the enrollment and 30.7% of the graduates in the program. The MBI program has the highest proportion of physicians, with physicians representing 41.3% of enrollees and 38.3% of the graduates. Physicians in the program tend to be established in their careers and taking on informatics as a new career, with many already reporting professional activity in the field. The average age of physicians in the Graduate Certificate program is 47.8 years and in the MBI program is 44.2 years.

The age distribution of students enrolled since 2007 shows that those in the programs of shorter duration (Graduate Certificate and MBI) tend of be of higher age than the longer programs (MS and PhD). The average age of students in the different programs respective is Graduate Certificate 44.0, MBI 43.6, MS 35.6, and PhD 39.2.

The majority of students in the program since 2007 pursue their studies on a part-time basis. In the Graduate Certificate Program, the average duration of enrollment (including current students) is 1.5 years and the average time to graduate is 2.6 years. In the MBI program, the average duration of enrollment is 3.1 years, while the average time to graduate is 3.9 years. These numbers tend to be relatively comparable for groups with different backgrounds, i.e., those with doctoral degrees, master's degrees, or medical degrees.

The numbers reported so far represent the entire program. As noted at the onset, the program actually has three tracks. While the clinical informatics track dominates the numbers, it is important to note the other two tracks in the program.

The second track in the program is the bioinformatics and computational biology (BCB) track. This track is available on-campus only, and has subject matter that is more computational in nature. Since the launching of this track in 2007, a total of 31 students have matriculated, with 24 in the master's degree programs and seven in the PhD program. (One PhD student had a previous MS from the clinical informatics track.) The program has had 11 graduates, eight with a master's degree and three with a PhD. (One master's graduate completed both the clinical informatics and BCB tracks.) This track is likely to see growth for a variety of reasons, including from the growing role of genomics and related areas in healthcare and biomedical research as well as OHSU's continued investment in quantitative biosciences.

The third track is the health information management (HIM) track, which was launched in 2008. The motivation for this track was to bring about more integration of the HIM and clinical informatics fields, and the curriculum has been structured accordingly, with students combining classes from the clinical informatics track as well as those specific to HIM. The program is accredited by the Commission on the Accreditation of Health Informatics and Information Management (CAHIIM), which allows students to sit for the Registered Health Information Administrator (RHIA) certificate. Since inception, a total of 56 students have enrolled, 17 of whom have graduated. Of the graduates, five have sat for and passed the RHIA certification exam. Just as the American Health Information Management Association (AHIMA) is calling for the HIM entry level to move to the master's degree level, we are expanding the HIM track to the master's degree programs and seeking CAHIIM accreditation at that level.

One final part of our program is the 10x10 ("ten by ten") program. This program was started in partnership with the American Medical Informatics Association (AMIA) in 2005, when then-AMIA President Charles Safran called for one physician and one nurse to be trained in informatics at each US hospital. OHSU operationalized this definition to become 10,000 individuals trained in informatics by 2010 (hence "10x10") and became the first partner with AMIA to offer such a course, which is a standalone version of the introductory course (BMI 510) in the clinical informatics and HIM tracks of the graduate program. At the end of the course, students can optionally take the BMI 510 final exam. If they receive a B grade or better, they can then receive graduate credit for the course upon matriculating in one of the graduate programs without paying additional tuition.

At the end of 2010, a total of 999 individuals completed the OHSU 10x10 offering. Because of continued interest in the course, we have continued to offer it, and by the end of 2011, 1169 people have now completed it. Of those people, 522 (44.7%) have passed the optional final exam, and about 15% gone on to enroll in one of the graduate programs (usually the Graduate Certificate but sometimes the master's program). One individual has "run the table" of OHSU education, starting in 10x10 and advancing to the Graduate Certificate, MBI, and PhD programs.

Secondary Use of Clinical Data, the TREC Medical Records Track, and "Big Data" in Biomedicine

Last week I had the opportunity to present my latest research activity at the OHSU Biomedical Informatics Conference we hold almost every Thursday during the academic year. I chose to present work about the TREC Medical Records Track and its place in the larger context of "secondary use" of clinical data in electronic health record (EHR) systems [1]. The impetus for this work grows with the increasing adoption of EHRs under the HITECH Act, along with the vision of the "learning healthcare system" [2].

I will not recapitulate the talk here, which covers the rationale, data, methods, and early results of the TREC Medical Records Track. (Details can be found on the video and slides from the talk.) I will, however, explore the relationship of what is increasingly called "big data" to biomedicine. One can easily find volumes of information on the Web about big data, but the vision is probably best articulated in the book, The Fourth Paradigm: Data-Intensive Scientific Discovery, published in 2009 by Microsoft Research [3]. This book presents visionary essays on how the growing amount of big data, from EHRs to biomolecular data to patient-entered data will facilitate new discovery of knowledge that conventional experiments will not. As other non-medical essays in the book show, this approach has led to many discoveries in other disciplines that use this form of eScience. We also know that businesses and others make productive use of the vast troves of data they collect from purchases, Web chatter, and other sources of information.

It is important to remember, however, that the existence of large volumes of electronic data does not guarantee that this data will automatically translate into knowledge. In my talk, I reviewed the unfortunately modest amount of literature on this topic. The bottom line, discussed and referenced in more detail below, is that medical records are not only incomplete, but they are also often much less meticulously kept than research data. As I have said in the past, clinical documentation is often what stands between the clinician's daily work and his or her going home for dinner. Another problem with medical records of course is that the data are observational and not experimental, so confounding factors can influence conclusions that might be drawn.

In preparing for this talk, I came across a somewhat obscure but well-written critique of big data [4]. As often happens, I found this paper almost by accident, being pointed to it by one of the email lists to which I subscribe. The primary author of the paper is Danah Boyd, who is another member of Microsoft Research and is also Research Assistant Professor in Media, Culture, and Communication at New York University as well as Visiting Researcher at Harvard Law School. (The paper was delivered as a keynote address at the Oxford Internet Institute's A Decade in Internet Time: Symposium on the Dynamics of the Internet and Society on September 21, 2011.)

Boyd and her co-author list six "provocations" for big data, which sum up to the best critique of big data I have seen. These provocations give us thoughts for concern and are all relevant to biomedicine.  I list them here along with my commentary for applicability in biomedicine or other general comments:

1. Automating Research Changes the Definition of Knowledge - In all research, we tend to meld the question to the data we can obtain. This has certainly been true in biomedical research, where some have criticized research with answering questions either of interest to the research or that have expediency in being able to answer [5, 6, 7]. We need to remember that the data available in electronic systems, big or small, similarly impacts the questions we ask.
2. Claims to Objectivity and Accuracy are Misleading - Just because data are collected in a disinterested way does not mean that bias does not occur. We certainly know from the clinical documentation setting (see above or [8]) that data entered by clinicians is not necessarily accurate, objective, or complete.
3. Bigger Data are Not Always Better Data - This has always been known in medicine from the context of those who do "claims" research based on data collected for billing purposes, which usually consists of diagnosis and procedures codes. One argument for this type of research is the sheer volume of such data, but we also know that this data does not give a complete picture of the patient [9, 10].
4. Not All Data Are Equivalent - We certainly know from the clinical setting that certain types of data (e.g., data collected by motivated researchers) are more likely to be of higher completeness and accuracy than others (e.g., clinical documentation) [11].
5. Just Because it is Accessible Doesn’t Make it Ethical - I agree with the author that the use of Institutional Review Boards is important but also has its limitations in keeping research ethical.
6. Limited Access to Big Data Creates New Digital Divides - I have seen this issue play out in information retrieval research, where the researchers from the big search engine companies have access to proprietary data, which makes peer review as well as reproducibility of the work difficult at best. I know Jimmy Lin personally, and it pains me to read his comment quoted in this paper.

In summary, EHRs provide great potential for improving health and the delivery of healthcare through the learning health system, but we also must remember the caveats of doing so. The consumers of this data need to be cognizant of its limitations but also supportive of the research that explores its more effective use.

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. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29.
3. Hey, T., Tansley, S., et al., eds. (2009). The Fourth Paradigm: Data-Intensive Scientific Discovery. Redmond, WA. Microsoft Research. http://research.microsoft.com/en-us/collaboration/fourthparadigm/.
4. Boyd, D. and Crawford, K. (2011). Six Provocations for Big Data. Cambridge, MA, Microsoft Research. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1926431.
5. Harari, E. (2001). Whose evidence?  Lessons from the philosophy of science and the epistemology of medicine. Australia and New Zealand Journal of Psychiatry, 35: 724-730.
6. Cohen, A., Stavri, P., Hersh W. (2004). A categorization and analysis of the criticisms of evidence-based medicine. International Journal of Medical Informatics, 73: 35-43.
7. Tunis, S., Stryer, D., et al. (2003). Practical clinical trials - increasing the value of clinical research for decision making in clinical and health policy. Journal of the American Medical Association, 290: 1624-1632.
8. Benin, A., Vitkauskas, G., et al. (2005). Validity of using an electronic medical record for assessing quality of care in an outpatient setting. Medical Care, 43: 691-698.
8. Jollis, J., Ancukiewicz, M., et al. (1993). Discordance of databases designed for claims payment versus clinical information systems:  implications for outcomes research. Annals of Internal Medicine, 119: 844-850.
9. O'Malley, K., Cook, K., et al. (2005). Measuring diagnoses: ICD code accuracy. Health Services Research, 40: 1620-1639.
10. Berlin, J. and Stang, P. (2011). Clinical Data Sets That Need to Be Mined, 104-114, in Olsen, L., Grossman, C. and McGinnis, J., eds. Learning What Works: Infrastructure Required for Comparative Effectiveness Research. Washington, DC. National Academies Press.

Connecting Informatics Research to Practice: Innovations for AMIA 2012

This year, I will be serving as the Scientific Program Committee (SPC) Chair for the AMIA 2012 Annual Symposium. The annual "AMIA meeting" is the most important biomedical and health informatics scientific meetings of the year, attracting the highest-quality submissions and otherwise providing a snapshot of the field through keynote talks, panels, and other sessions. I am honored to have been selected as SPC Chair for the 2012 meeting and, like many SPC Chairs before me, hope to make some innovations to the meeting that prove to be enduring in value. I was interviewed at the AMIA 2011 conference to give my perspective on the conference and my role in 2012.

The AMIA 2012 innovation I am most excited about is a new category of presentation we are calling the State of the Practice. This session type fits in well with my growing activity at the intersection between the science and practice of informatics. We hope to accept sessions led by experts and leaders from operational settings who will describe key problems and challenges whose solutions have answers in the scientific research of the field. These sessions will provide what all mature professions must have, which is robust and pertinent science that supports operational practice.

Another key AMIA 2012 innovation is a submission category for podium presentations of abstracts. As many AMIA authors and presenters know, the indexing of AMIA papers in the MEDLINE bibliographic database has been a mixed blessing. While it enables authors to have their work made more visible by indexing in the premier biomedical literature database, it also often precludes later, more substantive publication of the work in a scientific journal, due to rules around "prior publication." This new category of submission will allow authors to present their most innovative and cutting-edge work, with the abstract published in the proceedings but not indexed in MEDLINE, so that the author will retain complete flexibility for future publication of the work.

A couple other new changes will be the return of the tutorial program to presenter-initiated submissions (instead of commission by an AMIA committee) and a new pre-symposium program for AMIA Working Groups. The conference Call for Participation provides details on submitting for presentation.

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

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

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

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

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

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

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

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

I do wish everyone a healthy and prosperous 2012!

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

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

About Our Program

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

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

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

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

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

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

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

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

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

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

About Our Students

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Postscript: In early 2012, AMIA posted a page of frequently asked questions about the subspecialty: http://www.amia.org/faq-clinical-informatics-medical-subspecialty.)

References

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

Accolades for the Informatics Professor - Fall, 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

Update: Clinical Informatics Subspecialty Approved

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

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

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

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

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

More Studies Assessing Quality Improvement Using Electronic Health Records

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

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

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

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

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

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

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

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