Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.

Collaboration leads to enhanced curriculum.

BACKGROUND: In 2007, we initiated a health information management (HIM) track of our biomedical informatics graduate program, and subsequent ongoing program assessment revealed a confluence of topics and courses within HIM and clinical informatics (CI) tracks. We completed a thorough comparative analysis of competencies derived from AMIA, AHIMA, and CAHIIM. Coupled with the need to streamline course offerings, the process, described in this paper allowed new opportunities for faculty collaboration, resulted in the creation of a model assessment for best practice in courses, and led to new avenues of growth within the program. OBJECTIVE: The objective of the case study is to provide others in the informatics educational community with a model for analysis of curriculum in order to improve quality of student learning. METHODS: We describe a case study where an academic informatics program realigned its course offerings to better reflect the HIM of today, and prepare for challenges of the future. Visionary leadership, intra-departmental self-analysis and alignment of the curriculum through defined mapping process reduced overlap within the CI and HIM tracks. Teaching within courses was optimized through the work of core faculty collaboration. RESULTS: The analysis of curriculum resulted in reduction of overlap within course curriculum. This allowed for additional and new course content to be added to existing courses. CONCLUSIONS: Leadership fostered an environment where top-down as well as bottom-up collaborative assessment activities resulted in a model to consolidate learning and reduce unnecessary duplication within courses. A focus on curriculum integration, emphasis on course alignment and strategic consolidation of course content raised the quality of informatics education provided to students. Faculty synergy was an essential component of this redesign process. Continuous quality improvement strategy included an ongoing alignment of curriculum and competencies through a comparative analysis approach. Through these efforts, new innovation was possible.

Big Data: Are Biomedical and Health Informatics Training Programs Ready? Contribution of the IMIA Working Group for Health and Medical Informatics Education.

OBJECTIVE: The growing volume and diversity of health and biomedical data indicate that the era of Big Data has arrived for healthcare. This has many implications for informatics, not only in terms of implementing and evaluating information systems, but also for the work and training of informatics researchers and professionals. This article addresses the question: What do biomedical and health informaticians working in analytics and Big Data need to know? METHODS: We hypothesize a set of skills that we hope will be discussed among academic and other informaticians. RESULTS: The set of skills includes: Programming - especially with data-oriented tools, such as SQL and statistical programming languages; Statistics - working knowledge to apply tools and techniques; Domain knowledge - depending on one's area of work, bioscience or health care; and Communication - being able to understand needs of people and organizations, and articulate results back to them. CONCLUSION: Biomedical and health informatics educational programs must introduce concepts of analytics, Big Data, and the underlying skills to use and apply them into their curricula. The development of new coursework should focus on those who will become experts, with training aiming to provide skills in "deep analytical talent" as well as those who need knowledge to support such individuals.

Commentaries on the IMIA Award of Excellence Lecture by Reinhold Haux.

The IMIA Yearbook editorial team asked five internationally renowned biomedical informaticians to respond to Prof. Haux's editorial. This paper summarizes their thoughts and responses. Contributions are ordered alphabetically by the contributor's last name. All authors provided an equal contribution to this manuscript.

Education in Biomedical and Health Informatics in the Web 3.0 Era: Standards for data, curricula, and activities. Contribution of the IMIA Working Group on Health and Medical Informatics Education.

UNLABELLED: Web 3.0 is transforming the World Wide Web by allowing knowledge and reasoning to be gleaned from its content. OBJECTIVE: Describe a new scenario in education and training known as "Education 3.0" that can help in the promotion of learning in health informatics in a collaborative way. METHODS: Review of the current standards available for curricula and learning activities in in Biomedical and Health Informatics (BMHI) for a Web 3.0 scenario. RESULTS: A new scenario known as "Education 3.0" can provide open educational resources created and reused throughout different institutions and improved by means of an international collaborative knowledge powered by the use of E-learning. Currently there are standards that could be used in identifying and deliver content in education in BMHI in the semantic web era such as Resource Description Format (RDF), Web Ontology Language (OWL) and Sharable Content Object Reference Model (SCORM). In addition, there are other standards to support healthcare education and training. There are few experiences in the use of standards in e-learning in BMHI published in the literature. CONCLUSION: Web 3.0 can propose new approaches to building the BMHI workforce so there is a need to build tools as knowledge infrastructure to leverage it. The usefulness of standards in the content and competencies of training programs in BMHI needs more experience and research so as to promote the interoperability and sharing of resources in this growing discipline.

A medical informatics distance-learning course for Latin America. Translation, implementation and evaluation.

BACKGROUND: There is a growing need and interest worldwide for healthcare and information technology professionals trained in medical informatics. Distance learning technologies are increasingly used to deliver such education, but have mainly been limited to the English language. OBJECTIVE: Describe the implementation and student satisfaction of a medical informatics course delivered in Spanish for a Latin American audience. METHODS: The course was based on the 10 x 10 program of the American Medical Informatics Association and Oregon Health & Science University that was translated and adapted to the Latin American setting. The initial course consisted of ten one-week units, currently the course has 15 modules that are delivered in 16 weeks with topics that address the needs of medical informatics in the region. We also administered an anonymous questionnaire of student satisfaction. RESULTS: A total of 499 individuals have enrolled in the course, and 70% have completed it. Most of the students have been healthcare professionals (86%), with the largest proportion from Argentina. Student satisfaction with all aspects of the course was high. After the initial experience and feedback from the students, the course has been adapted to better meet regional needs. CONCLUSION: The initial experience obtained in training healthcare professionals in medical informatics in Latin America in their own language demonstrated that it could be used across the region, and this could represent a model for disseminating knowledge of medical informatics across other languages and cultures.

The health information technology workforce: estimations of demands and a framework for requirements.

BACKGROUND: There is increasing recognition that a competent and well-trained workforce is required for successful implementation of health information technology. METHODS: New and previous research was gathered through literature and Web searching as well as domain experts. Overall themes were extracted and specific data collated within each. RESULTS: There is still a paucity of research concerning the health information technology workforce. What research has been done can be classified into five categories: quantities and staffing ratios, job roles, gaps and growth, leadership qualifications, and education and competencies. From several countries it can be seen that substantial numbers of individuals are needed with diverse backgrounds and competencies. CONCLUSIONS: Additional research is necessary to determine the optimal organization and education of the health information technology workforce.

Commentaries on "Informatics and medicine: from molecules to populations".

OBJECTIVE: To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. "Informatics and Medicine: From Molecules to Populations". METHOD: Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper. RESULTS AND CONCLUSIONS: The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.

The full spectrum of biomedical informatics education at Oregon Health & Science University.

OBJECTIVES: The growing use of health information technology in operational settings, along with the maturation of the discipline of biomedical informatics, requires reorganization of educational programs in the field. The objective of this paper is to provide a context and description of the biomedical informatics education program at Oregon Health & Science University. METHODS: The details of the program are provided. RESULTS: The paper describes the overall program and its component curricula. CONCLUSIONS: OHSU has developed a program that caters to the full spectrum of those who will work in the field, allowing education tailored to their career goals and needs. The maturation of Internet technologies also allow most aspects of the program to be delivered on-line. The informatics field must step up to the challenge of educating the best workforce to achieve our goals for the optimal use of HIT.

Reducing workload in systematic review preparation using automated citation classification.

OBJECTIVE: To determine whether automated classification of document citations can be useful in reducing the time spent by experts reviewing journal articles for inclusion in updating systematic reviews of drug class efficacy for treatment of disease. DESIGN: A test collection was built using the annotated reference files from 15 systematic drug class reviews. A voting perceptron-based automated citation classification system was constructed to classify each article as containing high-quality, drug class-specific evidence or not. Cross-validation experiments were performed to evaluate performance. MEASUREMENTS: Precision, recall, and F-measure were evaluated at a range of sample weightings. Work saved over sampling at 95% recall was used as the measure of value to the review process. RESULTS: A reduction in the number of articles needing manual review was found for 11 of the 15 drug review topics studied. For three of the topics, the reduction was 50% or greater. CONCLUSION: Automated document citation classification could be a useful tool in maintaining systematic reviews of the efficacy of drug therapy. Further work is needed to refine the classification system and determine the best manner to integrate the system into the production of systematic reviews.

Using co-occurrence network structure to extract synonymous gene and protein names from MEDLINE abstracts.

BACKGROUND: Text-mining can assist biomedical researchers in reducing information overload by extracting useful knowledge from large collections of text. We developed a novel text-mining method based on analyzing the network structure created by symbol co-occurrences as a way to extend the capabilities of knowledge extraction. The method was applied to the task of automatic gene and protein name synonym extraction. RESULTS: Performance was measured on a test set consisting of about 50,000 abstracts from one year of MEDLINE. Synonyms retrieved from curated genomics databases were used as a gold standard. The system obtained a maximum F-score of 22.21% (23.18% precision and 21.36% recall), with high efficiency in the use of seed pairs. CONCLUSION: The method performs comparably with other studied methods, does not rely on sophisticated named-entity recognition, and requires little initial seed knowledge.

Clinical outcomes resulting from telemedicine interventions: a systematic review.

BACKGROUND: The use of telemedicine is growing, but its efficacy for achieving comparable or improved clinical outcomes has not been established in many medical specialties. The objective of this systematic review was to evaluate the efficacy of telemedicine interventions for health outcomes in two classes of application: home-based and office/hospital-based. METHODS: Data sources for the study included deports of studies from the MEDLINE, EMBASE, CINAHL, and HealthSTAR databases; searching of bibliographies of review and other articles; and consultation of printed resources as well as investigators in the field. We included studies that were relevant to at least one of the two classes of telemedicine and addressed the assessment of efficacy for clinical outcomes with data of reported results. We excluded studies where the service did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis). All included articles were abstracted and graded for quality and direction of the evidence. RESULTS: A total of 25 articles met inclusion criteria and were assessed. The strongest evidence for the efficacy of telemedicine in clinical outcomes comes from home-based telemedicine in the areas of chronic disease management, hypertension, and AIDS. The value of home glucose monitoring in diabetes mellitus is conflicting. There is also reasonable evidence that telemedicine is comparable to face-to-face care in emergency medicine and is beneficial in surgical and neonatal intensive care units as well as patient transfer in neurosurgery. CONCLUSIONS: Despite the widespread use of telemedicine in virtually all major areas of health care, evidence concerning the benefits of its use exists in only a small number of them. Further randomized controlled trials must be done to determine where its use is most effective.

Implementation and evaluation of a medical informatics distance education program.

OBJECTIVE: Given the need for continuing education in medical informatics for mid-career professionals, the authors aimed to implement and evaluate distance learning courses in this area. DESIGN: The authors performed a needs assessment, content and technology planning, implementation, and student evaluation. MEASUREMENTS: The needs assessment and student evaluations were assessed using a combination of Likert scale and free-form questions. RESULTS: The needs assessment indicated much interest in a medical informatics distance learning program, with electronic medical records and outcome research the subject areas of most interest. The courses were implemented by means of streaming audio plus slides for lectures and threaded discussion boards for student interaction. Students were assessed by multiple-choice tests, a term paper, and a take-home final examination. In their course evaluations, student expressed strong satisfaction with the teaching modalities, course content, and system performance. Although not assessed experimentally, the performance of distance learning students was superior to that of on-campus students. CONCLUSION: Medical informatics education can be successfully implemented by means of distance learning technologies, with favorable student satisfaction and demonstrated learning. A graduate certificate program is now being implemented.

Implementation and evaluation of a distance learning introductory course in medical informatics.

CONTEXT: There is a growing interest in and need for continuing education in medical informatics delivered by distance learning. OBJECTIVES: Implement and evaluate a distance learning introductory course in medical informatics. METHODS: A Web-based version of our on-campus "Introduction to Medical Informatics" course was implemented using streaming audio lectures, threaded discussion boards, and several other teaching modalities. Evaluation was performed using an adaptation of our on-campus course evaluation instrument. RESULTS: The course was implemented with no major technological or pedagogical problems. Student satisfaction with teaching modalities and other course modalities was high. CONCLUSIONS: The learning technologies used in this course were implemented successfully and a Graduate Certificate Program is planned to further meet educational needs in medical informatics.

Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions.

BACKGROUND: This report is a supplement to an earlier evidence report, Telemedicine for the Medicare Population, which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare. That report focused on telemedicine programs and clinical settings that had been used with or were likely to be applied to Medicare beneficiaries. While we prepared that report, it became apparent that there are also telemedicine studies among non-Medicare beneficiaries--e.g., children and pregnant women--that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications. In addition, the first evidence report only partially included a class of telemedicine applications (called self-monitoring/testing telemedicine) in which the beneficiary used a home computer or modern-driven telephone system to either report information or access information and support from Internet resources and indirectly interact with a clinician. Self-monitoring/testing applications in the first report required direct interaction with a clinician. The goal of this report is to systematically review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional. (In this report, we will refer to the latter as clinician-indirect home telemedicine.) Specifically, the report summarizes scientific evidence on the diagnostic accuracy, access, clinical outcomes, satisfaction, and cost-effectiveness of services provided by telemedicine technologies for these patient groups. It also identifies gaps in the evidence and makes recommendations for evaluating telemedicine services for these populations in the future. The evidence is clustered according to three categories of telemedicine service defined in our original report: store-and-forward, self-monitoring/testing, and clinician-interactive services. The three clinical practice areas reviewed in this report are defined as follows. The term pediatric applies to any telemedicine study in which the sample consisted wholly or partially of persons aged 18 or younger, including studies with neonatal samples. The term obstetric applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care. The term clinician-indirect home telemedicine applies to home-based telemedicine (called self-monitoring/testing in our original report) where a telemedicine application used in the home has only indirect involvement by the health care professional. Interactive home telemedicine was applied in this report to all patient populations. KEY QUESTIONS: The key questions that served as a guide for reviewing the literature in the evaluation of pediatric, obstetric, and clinician-indirect home telemedicine applications were derived by consensus among the evidence-review team based on the analytic framework established for the original evidence report. For the current report, the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services: store-and-forward; self-monitoring/testing; and clinician-interactive. The specific key questions were: 1. Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management? 2. Does the availability of telemedicine provide comparable access to care? 3. Does telemedicine result in comparable health outcomes? 4. Does telemedicine result in comparable patient or clinician satisfaction with care? 5. Does telemedicine result in comparable costs of care and/or cost-effectiveness? METHODS: We searched for peer-reviewed literature using several bibliographic databases. In addition, we conducted hand searches of leading telemedicine journals and identified key papers from the reference lists of journal articles. For our original evidence report on telemedicine for the Medicare population, we designed a search to find any publications about telemedicine and used it to search the MEDLINE, CINAHL, and HealthSTAR databases for all years the databases were available. Through this process, we captured studies of pediatric, obstetric, and clinician-indirect home telemedicine; however, they were excluded from the original report since they were outside its scope. For this supplemental report, we reviewed our original search results and identified studies relevant to this report. We identified additional studies from the reference lists of included papers and from hand searching two peer-reviewed telemedicine publications, the Journal of Telemedicine and Telecare and Telemedicine Journal. We critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies at weekly meetings of the research team. We also developed recommendations for research to address telemedicine knowledge gaps. To match these gaps with the capabilities of specific research methods, we classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met. We emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research. FINDINGS: We identified a total of 28 eligible studies. In the new clinical areas, we found few studies in store-and-forward telemedicine. There is some evidence of comparable diagnosis and management decisions made using store-and-forward telemedicine from the areas of pediatric dental screening, pediatric ophthalmology, and neonatalogy. In self-monitoring/testing telemedicine for the areas of pediatrics, obstetrics, and clinician-indirect home telemedicine, there is evidence that access to care can be improved when patients and families have the opportunity to receive telehealth care at home rather than in-person care in a clinic or hospital. Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization. There is some evidence that this form of telemedicine improves health outcomes, but the study sample sizes are usually small, and even when they are not, the treatment effects are small. There is also some evidence for the efficacy of clinician-interactive telemedicine, but the studies do not clearly define which technologies provide benefit or cost-efficiency. Some promising areas for diagnosis include emergency medicine, psychiatry, and cardiology. Most of the studies measuring access to care provide evidence that it is improved. Although none of these studies were randomized controlled trials, they provide some evidence of access improvement over prior conditions. Clinician-interactive telemedicine was the only area for which any cost studies were found. The three cost studies did not adequately demonstrate that telemedicine reduces costs of care (except comparing only selected costs). No study addressed cost-effectiveness. CONCLUSIONS: This supplemental report covering the areas of pediatrics, obstetrics, and indirect-clinician home telemedicine echoes the findings of our initial report for the Medicare domain, which is that while the use of telemedicine is small but growing, the evidence for its efficacy is incomplete. Many of the studies are small and/or methodologically limited, so it cannot be determined whether telemedicine is efficacious. Future studies should focus on the use of telemedicine in conditions where burden of illness and/or barriers to access for care are significant. Use of recent innovations in the design of randomized controlled trials for emerging technologies would lead to higher quality studies. Journals publishing telemedicine evaluation studies must set high standards for methodologic quality so that evidence reports need not rely on studies with marginal methodologies.

Knowledge integration: insight through the E-portal.

Data become information when they can be summarized and organized into logical patterns; information becomes knowledge when it can be manipulated for actionable decision making; knowledge becomes insight when contextually relevant and temporarily appropriate. This article describes how information technology can now be used to provide clinicians with access to both insight and information that is context- and event-sensitive. Collaboration between the American College of Physicians, medical knowledge experts, Oregon Health Sciences University (OHSU), and shared medical systems for framework and infrastructure combine to create the ideal environment of complementary and synergistic competencies. This article describes the research that is under way at OHSU to determine how to deploy medical knowledge derived from these sources and integrate it into the clinical workflow; it also examines a vision of how medical knowledge can be integrated in the future.