Friday, October 9, 2015

A Huge Week for Health IT/Informatics

This past week was a busy week in the health IT/informatics world, as the US government released a flurry of rules and documents around health IT. As I tell my students, it is great to be living in this ever-changing part of the history of our field.

Probably making the most news was the release of the rules for Stage 3 of the EHR Incentive (also known as "Meaningful Use") Program by the Centers for Medicare & Medicaid Services (CMS). The Meaningful Use Program has taken its share of lumps in the last year or two, with the challenges providers have had in meeting its Stage 2 criteria and how it has consumed bandwidth that might be put toward other innovation by the healthcare system as well as the vendors. CMS has seem to have gotten the message somewhat, and the new criteria do dial back some on the requirements.

With the new rule, Stage 2 will be modified significantly. Some acute relief will be provided in the form of reduced requirements, from the necessity of reporting only 90 days (as opposed to a full year) of annual reporting to modification of the "view, download, and transmit" (VDT) requirement from five percent of an EP's patient panel to one single patient and reducing the secure messaging requirement from five percent to just being required to have the capability.

Also changed in Stage 2 itself, now called Modified Stage 2, which will be in effect from 2015-2017. The number of objectives is reduced to ten for eligible professionals (EPs) and nine for eligible hospitals (EHs), with each having one or more measures. The objectives are:
  1. Protect Patient Health Information
  2. Clinical Decision Support (CDS)
  3. Computerized Provider Order Entry (CPOE)
  4. Electronic Prescribing
  5. Health Information Exchange
  6. Patient Specific Education
  7. Medication Reconciliation
  8. Patient Electronic Access
  9. Secure Electronic Messaging (EPs only)
  10. Public Health Reporting
Starting in 2018, Stage 3 will become active, with the same objectives as above but with some more rigorous criteria for some of the measures. There is, however, one qualification to Stage 3, which is the opening of a comment period for how it could be changed to align with the new value-based care rules for Medicare. With the addition of calls for Stage 3 to be delayed or outright abandoned, it is not clear what it will ultimately look like.

The full rule is available, as is a brief summary. As always, my preference is for a detailed overview that provides enough detail for the informed reader, somewhere in between the minimally informative short summary and the exhaustive detail of the entire review, which CMS has also provided. (Note to standards developers! I prefer this approach for documentation of standards as well, eschewing both the superficial overviews as well as hundreds-of-pages implementation guides.)

Always a companion to the release of rules for the EHR Incentive Program is the release of the Health Information Technology Certification Criteria by the Office of the National Coordinator for Health IT (ONC). However, as noted by ONC, going forward the EHR Incentive Program will be decoupled from Health IT Certification. The EHR Incentive Program will still required use of certified products, but certification will also be used for other health IT functionality. As with CMS, a short summary and the detailed rule are provided, with the only interim document at this time being a Powerpoint deck that was used in the Webinar ONC presented to describe the new criteria.

The week’s activities did not, however, stop with release of the meaningful use and certification rules. ONC also released a final version of its Federal Health IT Strategic Plan for 2015-2020.
The stated mission of the plan is to "improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most.” This will be achieved through four goals:
  1. Advance Person-centered health and self-management
  2. Transform health care delivery and community health
  3. Foster research, scientific knowledge and innovation
  4. Enhance the nation’s health IT infrastructure
One of the objectives of the fourth goal is to implement the Shared Nationwide Interoperability Roadmap, which was also released by ONC this week in its final Version 1.0 form. The roadmap was accompanied by an updated version of ONC's 2016 Interoperability Standards Advisory, which provides an exhaustive list of the best available standards and links to their implementation specifications. These releases were described in a blog post by ONC Director, Dr. Karen DeSalvo.

As if this week’s activities were not enough, last week was another major milestone, with the switchover to ICD-10-CM by hospitals physician offices, and others who bill in the healthcare system. Eerily similar to Y2K a decade and a half ago, there were very few reports of problems, presumably because the community was well-prepared. Of course, only time will tell, particularly if providers start having claims denied because of faculty coding.

Another recent event pertinent to all of the above occurred the week before, when I presented the inaugural Clinical Informatics Grand Rounds at OHSU. The Grand Rounds series will be part of our normal Thursday Conference Series, and I usually kick off the series each academic year. This year I chose to talk on the topic, HITECH and Meaningful Use: Results from the Grand Experiment and Future Directions. My talk (video and slides available) was built around a proclamation I made in this blog on January 24, 2010, in a posting entitled, Informatics Now Lives in a HITECH World:
"This is a defining moment for the informatics field. Never before has such money and attention been lavished on it. HITECH provides a clear challenge for the field to 'get it right. It will be interesting to look back on this time in the years ahead and see what worked and did not work. Whatever does happen, it is clear that informatics lives in a HITECH world now." Going forward, it will continue to be interesting to pause and reflect.

Thursday, October 1, 2015

Accolades for DMICE

As regular readers of this blog know, I periodically devote postings in this blog to accolades, usually for myself but sometimes for others. I would like to devote this posting to accolades for the many students and faculty in the Oregon Health & Science University (OHSU) Department of Medical Informatics & Clinical Epidemiology (DMICE). More details are provided in the recently published edition of our department newsletter. (Past newsletters are also available.

There are many accolades to point out in the newsletter (starting on page in parentheses):
  • Our new Accreditation Council for Graduate Medical Education (ACGME)-accredited clinical informatics fellowship has launched with its first two fellows (1)
  • Thirty-seven individuals graduated with degrees and certificates in biomedical informatics from OHSU in the 2015 academic year (2)
  • Faculty member Nicole Weiskopf, PhD receiving a Catalyst award from the Oregon Clinical and Translational Research Institute (OCTRI) (3)
  • Numerous faculty and students participating in OHSU Research Week in May, 2015 (4)
  • A surprise party celebrating 25 years at OHSU for myself and fellow faculty Mark Heland, MD (10)
  • New OHSU School of Medicine leadership appointments for Paul Gorman, MD and Heidi Nelson, MD (15)
One final accolade is particularly noteworthy to call out. We were recently informed that OHSU informatics students will be finalists in the 2015 AMIA Student Design Challenge. The theme of this year’s competition is, The Human Side of Big Data – Facilitating Human-Data Interaction. A number of student groups from around the country submitted entries to the competition, and four finalists were recently selected to present at the AMIA Annual Symposium in November. Two of those finalist groups consist of OHSU students:
  • Ashley Choi, Benjamin Cordier, Prerna Das, PhD, and Jason Li, MS will present on, “Take a Breather: Empowering Adherence & Patient Centered Research through Interactive Data Visualization, Social Engagement, & Gamification in Patients with Sleep Apnea.”
  • Michelle Hribar, PhD, L. Nelson Sanchez-Pinto, MD, Kate Fultz Hollis, MS, Gene Ren, and Deborah Woodcock, MBA will present on, “Learning from the Data: Exploring a Hepatocellular Carcinoma Registry Using Visual Analytics to Improve Multidisciplinary Clinical Decision- Making.”
I am delighted that our students were successful enough to get this far, and I hope that one of them emerges as the winner, as a group of OHSU informatics students did in last year’s event.

Monday, September 28, 2015

After 2018: The Future of Clinical Informatics Board Certification

I have noted in the past that I receive a steady stream of email from physicians asking about their eligibility for board certification in the clinical informatics subspecialty. I have created several posts that allow me to point them to a general answer, the most recent one of which was last year. My most prominent advice has always been for those who can get certified to do so prior to the end of the “grandfathering” period if they can.

I have also voiced my concerns about the whole process. This is not because I believe that board certification in clinical informatics is not a good thing. I do believe it provides an excellent professional recognition of the work physicians do in informatics.

But the process is problematic on several fronts. First, by choosing to have clinical informatics as a subspecialty of all specialties, we require all who are certified to maintain a primary medical specialty. Given that most medical specialties now have time-limited certifications, this can create a challenging situation for those who work predominantly in informatics. It also rules out certification for those who do not have a primary medical specialty, either because their certification lapsed, or they never pursued it in the first place. I know of plenty of highly capable physician-informaticians who are not eligible for board certification.

A second major problem concerns the title of this posting, which is what will happen in 2018. According to current rules, the grandfathering period will end at this time, and the only pathway to board certification will be a two-year on-site Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship. While such a fellowship (such as the one we have launched at Oregon Health & Science University) will serve as excellent training for a career in clinical informatics, I am not convinced it should be the only pathway by which one can become board-eligible. This is especially the case for the significant numbers of physicians who gravitate into informatics well into their careers and way beyond the end of their formal training. For a physician who has established a career and/or a family, it is unimaginable that he or she could give that up to return to the salary, relocation, and time commitment of a fellowship. This is also inconsistent with work in the 21st century, where professionals, especially in knowledge fields like medicine and informatics, transition to new career activities along the way. Requiring a two-year, on-the-ground experience to become a clinical informatics professional is a relic of 20th-century approaches to training, where you did all of your education before jumping into the workforce, never to return for more.

Our online graduate program at OHSU has shown there are other pathways to successful careers in clinical informatics. We have a track record of many of our physician graduates being hired into clinical informatics positions, including the coveted Chief Medical Informatics Officer (CMIO) role. We have had about 40 graduates successfully pass the board exam, and I am not aware of a single person who failed it. We have also demonstrated that online educational programs can not only provide knowledge, but also practical real-world experiences.

The problem of after 2018 is illustrated explicitly by three “case studies,” two of individuals who have emailed and another who is a current student in an educational program. Let’s look at their cases.

The first emailed to me, “I am planning to take the exam to become board certified. I have a valid medical license, recently matched into an internal medicine residency. I hold a master’s degree in biomedical informatics, and have experience in clinical informatics. I have a senior colleague who recently graduated from an internal medicine residency. He is planning to apply for the clinical informatics board exam, but the application requires that we should have at least three years of experience, which could not be practically possible given the hectic residency schedule.” This individual has more informatics training and experience than his senior colleague, who will be able to become certified during the grandfathering period, but he himself will come up against 2018.

The second emailed to me, “I am a current second-year resident in internal Medicine and I was hoping to get some advice regarding my path in clinical informatics. When I graduate from residency in June of 2017, I had planned on working as a hospitalist while completing OHSU’s online masters in clinical informatics.  My anticipated date of completion for which would be June of 2019. I had hoped to sit for the clinical informatics board certification at that time. Unfortunately because of my family, I will not be living in a city that I would be able to participate in one of the in-person fellowship programs. … If I am not eligible for grand-fathering, how important do you think it would be to be board-certified in clinical informatics vs. holding a master’s?”

The final individual is currently in an MD/PhD program. She will finish her dual degrees next year, in 2016. But she then will need to complete a residency in some specialty, which will end well after 2018. Despite having a PhD in biomedical informatics, this individual will not be eligible to sit for the board exam under the current rules.

I worry that the success of the clinical informatics subspecialty will be compromised by the post-2018 requirement of an ACGME-accredited fellowship. Clearly these fellowships are one of many possible pathways to obtain excellent training in clinical informatics. But having the fellowship be the only pathway to board certification may prohibit many highly capable physicians from achieving their full potential in clinical informatics. I do hope that more enlightened leaders within the American Board of Preventive Medicine (ABPM), ACGME, and other organizations will recognize these problems and provide additional pathways for physicians to train and become successful in clinical informatics.

Monday, August 31, 2015

Information is Different Now That You’re a Doctor: Introduction to Clinical Informatics

This blog posting is a reading assignment for Oregon Health & Science University (OHSU) medical students who will be attending a session I am leading in the Fundamentals block of their curriculum that introduces them to medicine and medical school. My goal for the session is to provide a high-level overview of the information-related issues and challenges they will deal with as physicians and in process introducing them to the field of clinical informatics.

Even though many medical students and physicians do not acknowledge it, information has always been a major focus of clinical practice [1]. Physicians have always spent a great deal of time with information, as evidenced by studies that describe time use of physicians. Even in the era before widespread use of computers in medical practice, physicians spent more of their time in “indirect” care of patients (50-67%), including reviewing results and performing documentation, than directly interacting with patient (15-38%) [2-7]. A more recent study of interns found that they spent nearly 40% of their time in front of a computer [8].

Likewise, physicians and medical students have been using health information technology (HIT) for decades. During this time, the role of HIT has changed dramatically from a useful tool for data access and occasional information retrieval to a ubiquitous presence that permeates healthcare and medical practice in myriad ways. Twenty-first century physicians face a much more information-intense world than their predecessors. The field that focuses on how information is acquired, stored, and used is called informatics, and when applied in medicine and other health-related disciplines is called biomedical and health informatics [9].

Why do physicians spend so much time dealing with information? One reason is that the quantity of biomedical knowledge continues to expand, with an attendant increase in the primary scientific literature, i.e., the 75 clinical trials and 11 systematic reviews published each day. [10] Secondary knowledge sources that summarize this information proliferate as well, not only for use by clinicians but also by patients and consumers. Medical knowledge no longer is the exclusive purview of physicians, as 80% of all Internet users have searched for personal health information [11].

Another major change in the use of HIT has been the rapid growth of electronic health record (EHR) adoption. As a result of the “meaningful use” financial incentives of the Health Information for Technology and Clinical Health (HITECH) Act [12, 13], there has been widespread adoption and use of the EHR, growing to 97% in hospitals [14] and 78% in physician offices [15]. Being able to use data and information also means understanding that the EHR is more than “charting,” and that its value goes beyond being able to read it. Clinicians must be facile with all aspects of the EHR, being able to easily move from one vendor system to another. They must also learn to take advantage of clinical decision support that aims to prevent errors in test ordering, prescribing, and other activities that improve diagnosis and treatment of patients [16].

There is also growing adoption of HIT by patients and consumers, who not only want to find information about their health and disease, but also desire to interact with the healthcare system the same way they interact with airlines, banks, and retailers, i.e., through digital means. Growing numbers of patients are participating in their care using technologies such as the personal health record (PHR) [17] and some are even accessing their own progress notes [18] and more [19].

In the meantime, those who purchase and pay for healthcare, along with patients, are demanding more accountability for the quality, safety, and cost of care [20, 21]. This has led to an expectation of measurement and reporting of healthcare quality of care as a routine part of participation in new care delivery mechanisms such as primary care medical homes and accountable care organizations [22]. Likewise, there is a growing application of the data analytics to improving healthcare [23].

Patients may receive care in different places, sometimes by choice but other times by circumstances beyond their control, such as emergencies. Ideally data should “follow the patient” and move readily across organizational boundaries via health information exchange (HIE) [24]. At the same time, telemedicine and telehealth applications extend the reach of healthcare systems and clinicians in both rural and urban settings [25].

The growing quantity of clinical and administrative data in clinical information systems also affords an opportunity for advanced analysis that can enable better deployment of resources and coordination of care, facilitate personalized and precision medicine, and advance clinical and translational research [26]. Together, these advances are moving healthcare toward the global vision of the learning health system, where information systems are used to capture our practice, analyze what we might have done correctly or improperly, and guiding our improvement [27, 28].

Further evidence for importance of these developments comes the recent establishment of the new medical subspecialty of clinical informatics [29]. Practicing physicians are now beginning to become board-certified in this new subspecialty, with the concomitant establishment of fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). A growing number of physicians hold titles such as Chief Medical Informatics Officer (CMIO).

It should be abundantly clear that information becomes very different when one transitions to becoming a healthcare professional. There are professional and legal expectations that clinicians must acquire, analyze, and evaluate different facets of information to provide the best possible care to individual patients and entire populations. One critical concept is that informatics is not the same as computer literacy. Computer literacy is one of many requirements to use informatics successfully, but knowing how to use a computing device (PC, tablet, or smartphone) is not the same as having skills in informatics, i.e., using that device to improve health, healthcare delivery, public health, or research.

As a physician, information is different in many ways. Critical decisions about patient care are based on information not only in their EHR, but also knowledge retrieved from scientific literature, textbooks, Web sites, and other sources. Information must be accurate, up-to-date, and applied properly. Physicians must also be effective stewards of a patient’s record, both in terms of keeping it accurate and up-to-date, and also doing the utmost to make sure it is kept private and secure.


1.    Shortliffe EH, Biomedical informatics in the education of physicians. Journal of the American Medical Association, 2010. 304: 1227-1228.
2.    Ammenwerth E and Spötl HP, The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians' activities. Methods of Information in Medicine, 2009. 48: 84-91.
3.    Tipping MD, Forth VE, Magill DB, Englert K, and Williams MV, Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine, 2010. 5: 353-359.
4.    Kim CS, Lovejoy W, Paulsen M, Chang R, and Flanders SA, Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine, 2010. 5: 329-334.
5.    Tipping MD, Forth VE, O'Leary KJ, Malkenson DM, Magill DB, Englert K, et al., Where did the day go?--a time-motion study of hospitalists. Journal of Hospital Medicine, 2010. 5: 323-328.
6.    Yousefi V, How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management, 2011. 18: 159-164.
7.    Victores AJ, Coggins K, and Takashima M, Electronic health records and resident workflow: A time-motion study of otolaryngology residents. Laryngoscope, 2015. 125: 594-598.
8.    Block L, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, et al., In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? Journal of General Internal Medicine, 2013. 28: 1042-1047.
9.    Hersh W, A stimulus to define informatics and health information technology. BMC Medical Informatics & Decision Making, 2009. 9: 24.
10.    Bastian H, Glasziou P, and Chalmers I, Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Medicine, 2010. 7(9): e1000326.
11.    Fox S and Duggan M, Health Online 2013. 2013, Pew Internet & American Life Project: Washington, DC,
12.    Blumenthal D, Wiring the health system--origins and provisions of a new federal program. New England Journal of Medicine, 2011. 365: 2323-2329.
13.    Blumenthal D, Implementation of the federal health information technology initiative. New England Journal of Medicine, 2011. 365: 2426-2431.
14.    Charles D, Gabriel M, and Searcy T, Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2014. 2015, Department of Health and Human Services: Washington, DC,
15.    Hsiao CJ and Hing E, Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. 2014, National Center for Health Statistics, Centers for Disease Control and Prevention: Hyattsville, MD,
16.    Sittig DF, Wright A, Osheroff JA, Middleton B, Teich JM, Ash JS, et al., Grand challenges in clinical decision support. Journal of Biomedical Informatics, 2008. 41: 387-392.
17.    Miller HD, Yasnoff WA, and Burde HA, Personal Health Records: The Essential Missing Element in 21st Century Healthcare. 2009, Chicago, IL: Healthcare Information and Management Systems Society.
18.    Delbanco T, Walker J, Darer JD, Elmore JG, Feldman HJ, Leveille SG, et al., Open Notes: doctors and patients signing on. Annals of Internal Medicine, 2010. 153: 121-125.
19.    Woods SS, Schwartz E, Tuepker A, Press NA, Nazi KM, Turvey CL, et al., Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study. Journal of Medical Internet Research, 2013. 15(3): e65.
20.    Berwick DM, Nolan TW, and Whittington J, The triple aim: care, health, and cost. Health Affairs, 2008. 27: 759-769.
21.    McDonald KM, Chang C, and Schultz E, Closing the Quality Gap: Revisiting the State of the Science - Summary Report. 2013, Agency for Healthcare Research and Quality: Rockville, MD,
22.    Longworth DL, Accountable care organizations, the patient-centered medical home, and health care reform: what does it all mean? Cleveland Clinic Journal of Medicine, 2011. 78: 571-589.
23.    Hersh WR, Healthcare Data Analytics, in Health Informatics: Practical Guide for Healthcare and Information Technology Professionals, Sixth Edition, Hoyt RE and Yoshihashi A, Editors. 2014, Pensacola, FL. 62-75.
24.    Kuperman GJ, Health-information exchange: why are we doing it, and what are we doing? Journal of the American Medical Informatics Association, 2011. 18: 678-682.
25.    Kvedar J, Coye MJ, and Everett W, Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Affairs, 2014. 33: 194-199.
26.    Safran C, Bloomrosen M, Hammond WE, Labkoff SE, Markel-Fox S, Tang P, et al., 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, 2007. 14: 1-9.
27.    Friedman CP, Wong AK, and Blumenthal D, Achieving a nationwide learning health system. Science Translational Medicine, 2010. 2(57): 57cm29.
28.    Smith M, Saunders R, Stuckhardt L, and McGinnis JM, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2012, Washington, DC: National Academies Press.
29.    Detmer DE and Shortliffe EH, Clinical informatics: prospects for a new medical subspecialty. Journal of the American Medical Association, 2014. 311: 2067-2068.

Tuesday, July 28, 2015

The ONC Health IT Curriculum Returns to Life

Long-time readers of this blog know that a substantial part of my work life around 2010-2013 involved developing the health information technology curriculum for the Office of the National Coordinator for Health Information Technology (ONC). I posted in this blog about the project when it was funded as well as it came to an end. As the project was winding down, one of my laments was that there was no further funding to maintain the curriculum. This did not mean it was still not a valuable resource, as many educators were continuing to use it and enhance it locally. We were fortunately able to find a home for the materials in the American Medical Informatics Association (AMIA) Knowledge Center.

I was pleased earlier this year when ONC announced a funding opportunity to update the materials and add four new areas of content relevant for improved healthcare delivery: population health, care coordination, new care delivery and payments models, and value-based care. I am even more thrilled to report that OHSU was one of seven institutions awarded nearly a million dollars in funding to carry out this update and enhancement.

The funding is for more than just updating the curriculum and adding the new topic areas. After the curriculum revision is complete, ONC will work with the awardees to establish a program to train incumbent healthcare employees whose roles, duties, or functions involve health IT. The training will be completed in five days or less to accommodate professionals with restricted schedules and will be offered in various settings, such as online, in-person, or train-the-trainer programs. In total, awardees will collectively train about 6000 incumbent healthcare workers (about 1000 per grantee) in team-based care environments, such as long-term care facilities, patient-centered medical homes, accountable care organizations, hospitals, safety net clinics, rural health, and other settings.

I am certain that I will have more to say periodically about the project and its progress. I am also confident that it will help expand capacity of health IT across the country.

Friday, July 10, 2015

What is the Difference (If Any) Between Informatics and Data Science?

I am increasingly asked to describe the difference between data science and biomedical informatics. Distinguishing these disciplines takes on added importance with the recent publication of the NIH Advisory Committee to the Director, National Library of Medicine (NLM) Working Group, report on the future of the NLM, which calls for NLM to become a leader in data science at NIH. NLM has of course historically been a leader in research and training in biomedical informatics.

What is, if any, the difference between informatics and data science? Let me start with definitions. I have written my own definitions of biomedical informatics [1] but for the sake of the community, let me quote the latest consensus definition from our professional association, the American Medical Informatics Association (AMIA) [2]: "Biomedical informatics (BMI) is the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health."

How is data science defined? It is not as easy to find an "official" definition of data science, but a good starting point might be the definition from Wikipedia, which is the "extraction of knowledge from large volumes of data that are structured or unstructured." The Wikipedia article references that definition from a paper by Vasant Dhar [3] and a blog posting by Jeff Leek. A Google search also points out some highly-cited sources from O’Reilly & Associates Media and Forbes Magazine. The Forbes article quotes the famous information scientist Hal Varian, who has noted, "The ability to take data - to be able to understand it, to process it, to extract value from it, to visualize it, to communicate it - that’s going to be a hugely important skill in the next decades." I myself have written that the core competencies of data science are statistics, especially machine learning; data-oriented computer programming, especially of querying databases; domain understanding where the analysis and interpretation will be applied; business processes; and communications.

I believe that whether data science is distinct from, partially overlapping with, or a subset of informatics is defined by how broadly one defines informatics. I tend to take a very broad definition of informatics, because I understand that its "sociotechnical" nature [4] covers many facets of data, information, and knowledge, including their technological as well as social context. Informatics recognizes that many aspects of data influence its use, aggregation, and interpretation. I have expressed concern in the past that data scientists need to understand research methodology, in particular how we distinguish cause-and-effect from correlation.

One possible way to answer the question of distinction between data science and informatics is to think about areas of informatics that are not ordinarily considered part of data science. I can think of (at least) several. One is usability. We know through the recent massive adoption of the electronic health record EHR) that there are significant usability challenges of current EHRs [5]. These not only adversely impact workflow, another important informatics topic, but may compromise safety. Another area of informatics we have come to recognize as critical is adherence to standards so that we may achieve better system interoperability. Finally, we also know that informatics is riddled with challenging "people and organizational issues" as information systems profoundly impact healthcare and individual health in many ways [6].

There is no question that what we can do with data is important for informatics, larger healthcare, and society as a whole. Informatics has recognized this for decades, but it also knows that there is much context beyond the data itself, and to this end, we are best served by viewing data science as a proper subset of informatics, certainly in the biomedical and health domain.


1. Hersh, W (2009). A stimulus to define informatics and health information technology. BMC Medical Informatics & Decision Making. 9: 24.
2. Kulikowski, CA, Shortliffe, EH, et al. (2012). AMIA Board white paper: definition of biomedical informatics and specification of core competencies for graduate education in the discipline. Journal of the American Medical Informatics Association. 19: 931-938.
3. Dhar, V (2013). Data science and prediction. Communications of the ACM. 56(12): 64-73.
4. Coiera, E (2007). Putting the technical back into socio-technical systems research. International Journal of Medical Informatics. 76(Supp 1): 98-103.
5. Zhang, J and Walji, M, Eds. (2014). Better EHR - Usability, workflow & cognitive support in electronic health records. Houston, TX, National Center for Cognitive Informatics & Decision Making in Healthcare.
6. Ash, JS, Berg, M, et al. (2004). Some unintended consequences of information technology in health care: the nature of patient care information system related errors. Journal of the American Medical Informatics Association. 11: 104-112.

Tuesday, June 30, 2015

In Defense of AHRQ: A Key Component of Healthcare Delivery Science

The Agency for Healthcare Research & Quality (AHRQ) is an unheralded government agency that performs a great deal of healthcare-related research out of proportion to its small size. Just browsing through the AHRQ Web site makes it clear that agency does a great breadth of work for its annual $400 million budget. Yet AHRQ has somehow attracted its share of detractors, including those in control of the House of Representatives budgeting process who propose to abolish the agency in next fiscal year. A divide-and-conquer strategy of increasing federal medical research elsewhere is also concerning.

Eliminating AHRQ would be a profound mistake, especially with the emergence of the new discipline of healthcare delivery science [1], which the American Medical Association (AMA) calls the "third science" of medicine after basic and clinical sciences. It has been obvious for a long time that while the biomedical perspective of disease and its treatment by the healthcare system are important, larger questions loom around the most effective ways to transfer biomedical knowledge into effective, safe, and efficient healthcare delivery. Given the disease-oriented focus of most research from the National Institutes of Health (NIH), the large biomedical research agency of the US government, AHRQ is the main US government funder of research that would fall under the rubric of healthcare delivery science. The AMA has put its weight behind healthcare delivery science through its Accelerating Change in Medical Education Consortium.

AHRQ suffers from a number of challenges. One is that its research focuses on the healthcare system, including areas from healthcare delivery science such as patient safety, change management, and delivering high-value cost-conscious care. There are unfortunately elements of the healthcare system whose interests do not always align with the most effective or efficient care. By the same token, AHRQ also funds research on evidence-based medicine, which helps determine not only what works, but also identifies what does not work. EBM has its detractors, some (though not all) of whom may be invested (financially or otherwise) in specific tests and treatments for diseases. Furthermore, as AHRQ also focuses on patient safety and healthcare system issues, its research may be harder to sell than diseases such as cancer or Alzheimer’s Disease. It is more difficult for there to be "grateful patients" to celebrate a well-designed healthcare system avoiding an error or complication that a patient never knew he or she might suffer. All of these issues were explored well in a recent Washington Post article.

Another challenge for AHRQ is its being a standalone agency within the Department of Health and Human Services (HHS). As such, it is not protected under the umbrella of the larger health-related agencies, such as the NIH or Centers for Disease Control (CDC). A further difficulty for AHRQ is that has always been viewed as being associated with healthcare reform, including its political aspects. As such, it has tended to be viewed with suspicion by political conservatives. (Which to me is rather odd, since conservatives should be the first to point out that markets work best when consumers have information, and few federal agencies produce more high-quality, actionable information than AHRQ.)

One supporter of maintaining AHRQ is Michael Millenson, who recently blogged some criticism of AHRQ but nonetheless made the case for keeping it. I agree with Millenson that AHRQ needs to improve its messaging and perhaps change its name. But instead of Millenson’s suggestion to focus on "translational medicine," I believe that AHRQ should re-describe what it does as healthcare delivery science. Much of what AHRQ already does falls under the umbrella of healthcare delivery science, including areas such as value-based care, quality measurement and improvement, patient safety, and even informatics.

One of the news articles cited above notes that AHRQ comprises 0.1% of the HHS budget. As some of what AHRQ does would likely be transferred to other federal agencies, it is unlikely that eliminating AHRQ would save the government much money. Furthermore, the research AHRQ performs on comparative effectiveness and efficient care might save the government much larger amounts of money in other places, such as the Medicare system. I hope that wiser heads in Washington will prevail and maintain AHRQ and the valuable work it provides.

(Disclaimer: AHRQ funds research of myself and the department I lead at Oregon Health & Science University through its expansive health IT portfolio and its Evidence-Based Practice Center Program, which is part of its larger Effective Healthcare Program.)


1. Pronovost, PJ and Goeschel, CA (2010). Viewing health care delivery as science: challenges, benefits, and policy implications. Health Services Research. 45: 1508-1522.

Sunday, June 28, 2015

My Choice of a Smartwatch

I am one of those people who is sometimes derisively called an Apple Fanboy. That is, I tend to buy most Apple products, and almost always have the latest iPhone or iPad. This led to people (including myself!) wondering if I would acquire an Apple Watch. What follows is not a product review, but rather my perceptions of smartwatches based on my particular needs.

I have two major uses for a wristwatch. The first is that I remain one of those people who looks to my wrist and not my phone when I want to know the time of day. The second is that I am a devoted runner and enjoy tracking my running via GPS devices. I am not one of those “quantified self” types and am not particularly interested in how many steps I take during the day. But I do have fun tracking places I have run, especially when not in Portland. I have had great runs over the years in SingaporeBuenos Aires, Argentina; Bangkok, ThailandBeijing, China; Jerusalem, Israel; Frankfurt, Germany; Mexico City, Mexico; Cape Town, South Africa; Gabarone, Botswana; Copenhagen, Denmark; Dublin, Ireland; and elsewhere. I also have some favorite routes in Chicago; Washington, DC; and San Francisco. In addition, I have my usual routes in Portland, e.g., for running and cycling.

Based on these two needs, I decided not to purchase an Apple Watch, at least in its first iteration. I see the initial Apple Watch as more of an iPhone accessory than a standalone watch. On the other hand, I have had a succession of Garmin sports watches that have handled my second wristwatch need without needing to be tethered to my iPhone. I am particular enamored with the new Garmin vivoactive watch, which connects to my iPhone via Bluetooth and gets rid of the hassle of earlier Garmin GPS watches that required data transfer via cables or wireless with specific devices needing to be plugged into the computer’s USB port (Ant+). Once the data is transferred to my iPhone, it is then automatically uploaded to the Garmin Web site.

Some have asked, why not just run with your iPhone? I actually occasionally do that, but I do not want to be required to do so. I prefer to have all my GPS tracking done with only a watch, and I have no desire to carry my iPhone each time I want to track a run, especially in inclement weather (such as Oregon rain).

The vivoactive has a number of other interesting features. One is that the watch now actually has a software platform, ConnectIQ, that allows development of apps, such as different watch faces and those aimed at specific sports. (I mainly use my watch for running and cycling, and the built-in apps are fine for that.) The watch also provides notifications (vibration and short display) of those emanating from the phone, such as text messages, incoming calls, and calendar reminders. In short, the vivoactive could be the smartwatch that the Apple Watch should have been, although I have to admit that I may at some point discontinue the notifications from my iPhone, since I do not always want the distraction.

I have not tried any other smartwatches, nor other tracking devices such as the FitBit. I cannot imagine I would find them that useful. I do recognize that newer technologies may come along in the future and change my approach, but for now I am content wear my vivoactive on my wrist and use it to track my runs. (And in case anyone is wondering, I do not own stock in either Garmin or Apple.)

Thursday, June 18, 2015

Re-Affirming the National Library of Medicine

Last week, National Institutes of Health (NIH) Director Dr. Francis Collins accepted a report from his Advisory Committee to the Director (ACD) that set forth a strategic vision that affirmed the National Library of Medicine (NLM) as a strategic leader in data science, biomedical informatics, and as a library resource. This report was prompted by the retirement of Dr. Donald A.B. Lindberg as Director of the NLM for over 30 years. I have written before on how important the NLM has been to my career, and I am sure many other informaticians, especially those in academia, can attest likewise.

Input to the report came mainly from a Request for Information (RFI) issued by NIH in February, 2015. My response was among the 650 received by NIH, and was reproduced in a blog posting. Like many of my informatics colleagues, I called on NIH to re-affirm the importance of NLM, and its underlying biomedical and health informatics (BMHI) research and education agenda.

The ACD report put forth six recommendations, which I will list here and interpreted by me in italics:
  1. NLM must continually evolve to remain a leader in assimilating and disseminating accessible and authoritative biomedical research findings and trusted health information to the public, healthcare professionals, and researchers worldwide. NLM should continue its role as the world’s premier medical library.
  2. NLM should lead efforts to support and catalyze open science, data sharing, and research reproducibility, striving to promote the concept that biomedical information and its transparent analysis are public goods. NLM should expand its library role to advocate for and lead efforts in open data and science.
  3. NLM should be the intellectual and programmatic epicenter for data science at NIH and stimulate its advancement throughout biomedical research and application. NLM should the NIH home for data science, including the Big Data to Knowledge (BD2K) program, and biomedical informatics research.
  4. NLM should strengthen its role in fostering the future generation of professionals in biomedical informatics, data science, library sciences, and related disciplines through sustained and focused training efforts. NLM should continue its robust education and training activities.
  5. NLM should maintain, preserve, and make accessible the nation’s historical efforts in advancing biomedical research and medicine, thereby ensuring that this legacy is both safe and accessible for long-term use. NLM should maintain its role in archiving all aspects of science, including data.
  6. New NLM leadership should evaluate what talent, resources, and organizational structures are required to ensure NLM can fully achieve its mission and best allocate its resources. NLM should seek out the most skilled and talented people to pursue its mission and activities.
While I am overall highly supportive of the report, I do have a few small quibbles with it. One is the decision to focus on “data science” as opposed to larger BMHI. Data science is certainly an important field, and I am pleased to see NLM recognized as its NIH home for it. However, it would have been more visionary to embrace the optimal use of information to improve individual health, healthcare, public health, and biomedical research, i.e., the larger discipline of BMHI, as the critical mission of the NLM. We cannot have good data science without attention to other aspects of informatics, including but not limited to usability of systems, workflow, and standards and interoperability.

A second concern, related to the first, is the report's modest attention to clinical informatics. While clinical informatics does not represent the entirely of the larger BMHI, NLM is the only US federal research-related entity focused on basic research in clinical informatics, the branch of BMHI that focuses on the use of informatics for patients and in healthcare. The report does call for developing talent in research areas related to the electronic health record and analysis of biomedical text, but these do not represent the entirety of clinical informatics.

A final quibble, although I did not expect it to be addressed, concerns the name of NLM. While I recognize its library function as critically important, many who do not know the breadth of what NLM does may not fully appreciate the work it performs beyond its library role. While I understand it would literally take an act of Congress to change its name, I believe it would be much more logical for NLM to be called something like the National Institute for Biomedical and Health Informatics, with the NLM within it serving its critical library role.

These small issues notwithstanding, I am pleased to see the NLM, and its biomedical and health informatics research and training agenda, endorsed by the report. As such, I believe that the future of the NLM is bright, and now the NIH can get on with hiring the next NLM Director, who will hopefully be guided by the vision of informatics rightfully achieving its value in improving the health of the US and the rest of the world via its information ecosystem.

Wednesday, June 3, 2015

Informatics is Important When Information Is Important

Many of us in the informatics field, myself included, sometimes believe that the value proposition of informatics is so intuitively obvious that we do not need to explain it to the rest of the world. API-based interoperability? Secondary use of clinical data? Standardized terminology? Their value is so certain that we need not explain it. Not!

However, informatics is in the mainstream of healthcare now, and healthcare recognizes that using data and information to improve processes and outcomes while reducing costs is an essential part of doing business. Clearly there is room for improvement in how operational informatics is being done, but there is no turning back. This means that the priorities for our field are now driven largely by forces external to it. This is not necessarily a bad thing, as we must adapt to play our role optimally for the greater benefit to healthcare.

The main driver for the importance of data and information is changing care delivery models. Some of this can be attributed to the Affordable Care Act (aka, Obamacare), but in reality, healthcare has been changing for some time. The centerpiece of this change is a move away from "volume-based" to "value-based" payment. This is certainly true in the Medicare system, where a goal for the next few years has been established such that the majority of reimbursement will have some modification by quality or value, with half of all payments made through alternative payment models, such as accountable care organizations [1].

By contrast, in the older, volume-based "fee-for-service" model of reimbursement, information is not as important. The physician or the hospital provide their care and are reimbursed for it. Information is mostly important to the extent that all charges are captured.

But in the new value-based payment world, information becomes more important. Whether the physician or hospital is paid under a capitated model or as a bundle for specific diagnoses and/or procedures, there is some element of financial risk on the part of the provider. Especially when combined with a requirement for quality measures, the physician or hospital has incentive to provide the best care at the lowest cost. Information becomes much more important when there is motivation for quality, efficiency, and reduction of complications. The route to that information is through the proper application of informatics.

In this new value-based world, information becomes more important as it allow better management of costs and quality. In an article last year, Bates et al. laid the most important areas for managing high-risk and high-cost patients from the growing volume of data [2]:

  • High-cost patients – looking for ways to intervene early
  • Readmissions – prevention
  • Triage – selecting appropriate level of care, including transfer vs. staying in community
  • Decompensation – early detection of patient’s condition worsening
  • Adverse events – rapid detection and ability to act
  • Treatment optimization – especially for diseases affecting multiple organ systems
This provides a nice list of the priorities for capture and use of information as a driver to increase quality while reducing the cost of care. Informatics is now mainstream, and must become part of the larger healthcare team. It does not mean that our larger visions no longer matter, but rather that we must work with the rest of the system for the betterment of patients.


1. Burwell, SM (2015). Setting value-based payment goals - HHS efforts to improve U.S. health care. New England Journal of Medicine. 372: 897-899.
2. Bates, DW, Saria, S, et al. (2014). Big data in health care: using analytics to identify and manage high-risk and high-cost patients. Health Affairs. 33: 1123-1131.

Tuesday, May 26, 2015

Is Medicine Precise Enough to Achieve Precision Medicine?

One of the aspects of medicine that struck me as a medical student was its imprecision. I was surprised, sometimes shocked, at decisions that were made based on vague symptoms reported by patients, ambiguous findings detected on physical examination, and even variation in "hard" measurements such as laboratory results. An area of even more imprecision was the data in the patient record, which seemed to matter less when it was scribbled on paper but takes on a whole lot of importance more now that the data is electronic form and advocated for "secondary use."

It is against this backdrop that I view medicine entering the era of "precision medicine" [1]. The vision and potential for precision medicine is compelling and exciting. The notion that we can unravel the myriad of details of a patient's health or disease, and treat the latter more precisely, would be a genuine advance. The charge for precision medicine is being led by the new NIH $215 million Precision Medicine Initiative launched by President Obama.

As a researcher, especially one with an interest in the secondary use of the growing amount of clinical data [2,3], particularly from the electronic health record (EHR), I am naturally exciting about contributing to the advance of precision medicine. But as an educator, I usually try to step back and take a more holistic view. We must evaluate not only the specific components of precision medicine, but also the general paradigm. I believe there are challenges for both.

Focusing first on components of precision medicine, let us look, for example, at an area like genomics. Although I find genomics very intellectually fascinating, its impact on patient outcomes has been modest [4]. While our ability to sequence genomes and measure their expression continues to improve while costs fall at a rate exceeding Moore's Law for computers, only a modest amount of what we can measure has been "clinically actionable." Furthermore, although we tend to think of gene sequencing as very precise, it turns out that it too has imprecision. Last year, a study of two commercial whole genome sequencing platforms found that medians of 9-17% of 56 genes recently identified as having potentially high clinical importance were not covered by sufficient numbers of repeated sequencing reads to achieve clinical grade variant detection [5]. While whole genome sequencing is likely to improve, and it is not the only way to assess genomic variation, these data show that even gene sequencing can be imprecise.

Another specific area of challenge is clinical data, whose imprecision has also been long known. In 2013 I authored a paper on its "caveats" [2], and last year I recounted a situation where getting data back to its native form would be like unscrambling eggs. Just recently I heard an overview about our institutional plans for precision medicine, and walking away from a meeting with a clinical colleague, she was lamenting how the switch-over to ICD-10 for coding diagnoses on radiology ordering had just become a whole lot harder at our hospital because of the vastly increased number of codes. Her residents were overwhelmed by the choices, so often sought out the "not otherwise specified" code, which of course was often not the correct one to choose.

Also a concern about the components of precision medicine is how we will figure out what works. Although a proponent of the evidence-based medicine (EBM) approach, I am well aware of the limits of EBM that homogenize patients into large groups in order to determine an effect of a test or treatment. The nature of "best evidence" studies often glosses over individual differences. This provides a benefit in allowing statistical analysis to discern bias and chance from truth, but at the cost of ignoring personal differences. In precision medicine, when each individual is unique, how will we be able to experimentally compare different diagnostic tests and precision-based treatments?

I also believe that we will need to validate the paradigm of precision medicine. Indeed, this may be a way to overcome some of the EBM-related challenges, in that we may be able to apply experimentation to the precision medicine approach rather than any particular (individualized) therapy. Although hopefully there will be some tests and treatments with widespread enough use to conduct clinical trials.

In any case, the era of precision medicine portends an interesting and likely highly beneficial approach to medicine. The role of informatics will be widespread and important. Many of the issues that plague informatics, especially clinical data, currently (e.g., lack of standards and interoperability, ability to aggregate across healthcare systems, need to integrate with genomics and other bimolecular data) will need to be solved for informatics to make its optimal contribution.


1. Collins, FS and Varmus, H (2015). A new initiative on precision medicine. New England Journal of Medicine. 372: 793-795.
2. Hersh, WR, Weiner, MG, et al. (2013). Caveats for the use of operational electronic health record data in comparative effectiveness research. Medical Care. 51(Suppl 3): S30-S37.
3. Hersh, WR, Cimino, JJ, et al. (2013). Recommendations for the use of operational electronic health record data in comparative effectiveness research. eGEMs (Generating Evidence & Methods to improve patient outcomes). 1: 14.
4. Green, RC, Berg, JS, et al. (2013). ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genetics in Medicine. 15: 565-574.
5. Dewey, FE, Grove, ME, et al. (2014). Clinical interpretation and implications of whole-genome sequencing. Journal of the American Medical Association. 311: 1035-1044.

Monday, May 11, 2015

Semantic Drift and the Persistence of Informatics

Being concerned with representation of information and knowledge, researchers in informatics sometimes express concern with the concept of "semantic drift," where the meaning of words and concepts changes over time. Semantic drift happens for a variety of reasons, most commonly due to advancing and changing knowledge of health and biomedicine. Another type of semantic drift occurs in many industries, including the information technology (IT) industry, where new terms come along reflecting evolution in technology, although sometimes the new terms are just a different name for a similar or sometimes the same thing. Not infrequently, the new terminology reflects marketing and hype as much as substantive change.

Some terms withstand the test of time, and I am pleased to note that "informatics" fits into that category. The word traces its origins back to the 1960s, and the importance of the discipline has withstood the test of time. As with all fields, the leading edge has changed substantially, but the core function and definition of the field - the use of data, information, and knowledge to improve human health - has not.

Like many fields, informatics has seen the emergence of areas of work that overlap with its work, in essence that provide semantic drift not only from the core definition of informatics but also the description of work that rightfully belongs to it. I am referring to some of the emerging "hot topics" in recent years, such as data science, data analytics, and precision medicine. I suspect that some may argue these are different from informatics, but I would rebut that they really fit under the broad umbrella of informatics.

I also believe these new sub-disciplines need to prove their work, just as informatics has (or in some cases has not). Like most established disciplines, informatics has a long trail of science. Not all of it is strong methodologically, particularly the portion that evaluates systems in the real world. But we can point to techniques and implementations that have been studied enough to demonstrate where they do and do not work [1-4]. Informatics also provides a good deal of experience and perspective in having tried to address some of what these new sub-disciplines are trying to accomplish.

The current hot topic is precision medicine [5-6]. While I share the excitement and recognize its potential, I also know that it is still an unproven science. In other words, there are still few "products" of precision medicine that demonstrated any large-scale success. This does not mean precision medicine will not have such benefit, or that further research should not be pursued. But we also need to look for its results, especially those that lead to improved health and of outcomes from treatment of disease. The same holds true for the previous hot topic before precision medicine, namely data analytics and other aspects of Big Data.

In the meantime, I would encourage those who are pursuing these emerging areas to find a home in the larger science of informatics. Indeed, those from the informatics community are working in them (myself included), and we should show there is a solid trail of science leading into them and eschew that they are somehow completely brand new.


1. Chaudhry, B, Wang, J, et al. (2006). Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine. 144: 742-752.
2. Goldzweig, CL, Towfigh, A, et al. (2009). Costs and benefits of health information technology: new trends from the literature. Health Affairs. 28: w282-w293.
3. Buntin, MB, Burke, MF, et al. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs. 30: 464-471.
4. Jones, SS, Rudin, RS, et al. (2014). Health information technology: an updated systematic review with a focus on meaningful use. Annals of Internal Medicine. 160: 48-54.
5. Collins, FS and Varmus, H (2015). A new initiative on precision medicine. New England Journal of Medicine. 372: 793-795.
6. Ashley, EA (2015). The Precision Medicine Initiative - a new national effort. Journal of the American Medical Association, Epub ahead of print.

Tuesday, April 28, 2015

Toward Sustainable Funding for Clinical Informatics Fellowships

I have written before that one of the key challenges facing the new clinical informatics subspecialty is the funding of training fellowships. This is just one of the many "square pegs into round holes" problems of clinical informatics training not meshing with the traditional approach to clinical subspecialty fellowships.

The major problem is that most clinical subspecialty fellowship training in medicine is funded in part, even if only indirectly, by the service contributions that fellows make to the clinical unit in which they are training. A cardiology fellow, for example, is providing cardiology service to his or her department, which can either be billed or, if billed by the attending physician, allowing that attending physician to extend his or her capacity. This is in distinction to how most advanced education is funded, where a tuition model (either directly paid by the student or subsidized by someone else, such as a state government or training grant) pays the cost.

While a clinical informatics fellow will hopefully make contributions to the health system in which he or she is training, it is a bit of a stretch to believe they are providing monetary value for their service. At best, the health system is investing in these fellows because they are building informatics capacity in their organizations, which may translate into cost savings as value-based reimbursement models are undertaken (e.g., accountable care organizations).

If we are going to require physicians being trained in clinical informatics to do so via the traditional fellowship model, how are we going to pay the cost of their training? Some health systems might find value and foot the bill, as some already are. But it is not clear how sustainable this model is. If a health system comes on hard times financially and needs to cut costs, the clinical informatics fellowship might be an area that is reduced or eliminated.

Therefore a clinical informatics fellowship model must include a means for fellows to generate revenue for at least part of the their training. One obvious way to do this is allowing these fellows to practice in their primary medical specialty and bill (or otherwise be remunerated) for their work. Accreditation Council for Graduate Medical Education (ACGME) rules actually require clinical informatics fellows to maintain active practice in their primary specialty during their fellowship time (i.e., not moonlighting). Their work in clinical informatics will usually be distinct from their clinical practice, as clinical informatics work is likely to be applied to the entire health system and not just the fellow's primary specialty.

A problem with the fellowship trainee billing, however, is that it comes up against Center for Medical and Medicaid Services (CMS) rules that do not allow clinical trainees to "double dip." That is, most health systems with graduate medical education programs (i.e., residency and fellowship training) receive a subsidy from CMS Medicare funding to pay for physician training. Most health systems interpret this to not allow residents and clinical fellows to bill for their patient care work. But clinical informatics, like a number of other emerging subspecialties that emanate from multiple primary specialties, is truly different from the clinical practice component of the primary specialty.

To this end, I have recently collaborated with several of my colleagues leading clinical informatics fellowship programs to publish an open letter to CMS asking for guidance on clinical fellows being able to bill for their work so that clinical informatics fellowships can achieve financial sustainability [1]. We published this letter in the journal Applied Clinical Informatics and will be engaging with other medical subspecialties to achieve clarification from CMS on this issue. In addition, the leadership of the American Medical Informatics Association (AMIA) is working with other subspecialties in a similar situation to provide a larger picture of the problem, which we have learned is not unique to clinical informatics. The hope of clinical informatics fellowship leaders is that fellows will be allowed to function as attending physicians for their clinical practice in their primary specialty, and that this will allow a more sustainable funding model for clinical informatics fellowships.


1. Lehmann, CU, Longhurst, CA, et al. (2015). Clinical informatics fellowship programs: in search of a viable financial model - an open letter to the Centers for Medicare and Medicaid Services. Applied Clinical Informatics. 6: 267-270.

Thursday, April 9, 2015

Accolades for the Informatics Professor: Leadership Award at HIMSS and Other Notables

Time for one of my periodic postings on accolades for the Informatics Professor. Probably the major one concerns next week's Healthcare Information Management Systems Society (HIMSS) conference, where I will be receiving the HIMSS Physician IT Leadership Award. I am honored to receive this award and to be among so many other special award winners. Others have also picked up on the award, including MedTech Boston and HITECH Answers.

The HIMSS Award is not my only recent accolade. I was quoted in a story in the Portland Business Journal about the role of our program in the IBM-Epic bid to replace the Department of Defense military electronic health record system.

I also gave a Future Talk at New Relic, Inc., a Portland-based software analytics company on March 9, 2015. Entitled, Big Data in Healthcare and Biomedicine: Opportunities and Challenges, the talk, with links to my slides and a video, was written up in their company blog.

Monday, April 6, 2015

HITECH and Meaningful Use at a Crossroads

It is hard to believe that the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed into law five years ago, in 2009, and at the end of the year, the massive legislation was shaped into a program that has profoundly altered the informatics world, not to mention all of healthcare. Like most large undertakings, especially when infused with politics, the results have been mixed. Clearly the goals of EHR adoption have been substantial in hospitals and by physicians, even if the resulting systems have not achieved the ideals we held out for them. Perhaps as much depending on your political views as much as your informatics views, the glass is either partially empty or partially full.

On the positive side, a large proportion of US physicians [1] and nearly all US hospitals [2] now use an electronic health record. While many have argued that there should have been a much greater focus from the start on data interoperability, we are seeing progress with the rapid coalescence behind the FHIR, ReST, and OAuth2 standards in the Argonaut Project of HL7.

On the negative side, the systems we have implemented have been driven by meaningful use criteria. While no one would argue against these criteria generally (e.g., problem lists, electronic prescribing, etc.), many have argued that healthcare organizations have had to devote too much effort to meeting the criteria rather than innovating and leading with the beneficial aspects of technology. By the same token, the focus of vendors has had to be on certification to insure their customers can meet the meaningful use criteria with their products. On top of this is the toxic political environment in the US, with one's views' on HITECH and the Affordable Care Act being a sort of political Rorschach Test, making it even more difficult to have a meaningful conversation.

I tend to be glass-half-full kind of person, although I certainly acknowledge the limitations of the situation we are in now. It is easy to find critics of the current situation, but I tend to prefer to read and converse with those who present a balanced view that recognizes the problems in paper-based healthcare that led us to adopt the (still not achieved) promise of information technology (IT)-enabled healthcare. I give a special call-out to my colleagues Bob Wachter [3] and Jacob Reider [4] for their recent writings, and the former for his book that was just released [5], which I am enjoying but admittedly not done reading yet.

The real question is how we can get from here to where we want to be. This is especially so with the release of the Notice of Proposed Rule Making (NPRM) for Meaningful Use Stage 3 as well as the legislation to solve the Sustainable Growth Rate (SGR) problem (the "doc fix") of Medicare, which contains a proposal to roll the Meaningful Use Program into a more coalesced approach to incentives for quality in the Medicare Program.

My own view is that we should be focusing on data standards and interoperability, aiming to allow innovation to flourish on top of it. We also need to be open and critical of current failings, but also willing to move beyond negativity and linking the current situation to politics and/or greed. Not that both of these are not present, but that we need to come together as a community so those negative attributes are held in check by the greater community working toward more positive goals.


1. Charles, D, Gabriel, M, et al. (2014). Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: 2008-2013. Washington, DC, Department of Health and Human Services.
2. Hsiao, CJ and Hing, E (2014). Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Hyattsville, MD, National Center for Health Statistics, Centers for Disease Control and Prevention.
3. Wachter, B (2014). Meaningful Use. Born, 2009, Died, 2014? Wachter's World, November 13, 2014.
4. Reider, J (2015). Spring Deliveries from Washington. The Health Care Blog, March 22, 2015.
5. Wachter, R (2015). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York, NY, McGraw-Hill.

Saturday, March 21, 2015

When Bad Governments Happen to Good People

One of the most enjoyable aspects of my job is the opportunity to visit many different countries to collaborate with colleagues and friends in all sorts of informatics settings. I have written before that informatics is a field of global truths, and the benefits and challenges of implementing information systems in healthcare settings are universal across the world. Mixing healthcare and information technology no matter what kind of health system or technology infrastructure a county has.

Some of the countries I visit have governments whose policies and/or actions I consider disagreeable. How do I rectify this? The main way I do is recognize that those who invite me are doing so to share ideas and activities around informatics. As we are part of the larger biomedical and health community, we are driven by the creed that drives all health professions, which is to improve the health of individuals and populations. We do this in informatics by focusing on effort to improve health through better use of data, information, and knowledge.

There are certainly places I visit colleagues where the policies of their particular government are not agreeable to me. On the other hand, I do not always agree with the policies of my own government in the United States, although I do cherish our political system that lets me speak out about it, which is not always the case in places I visit. In any case, my view on visiting countries where I have wonderful colleagues but whose government I find disagreeable is that I do not need to to support a particular government if I am going to interact with my colleagues who live in that country. As my own country's track record in international relations is far from perfect, I can engage in honest discussion when the topic of politics arises. While I do not overtly criticize the governments who policies and actions with which I disagree, I will not hesitate to speak my opinion when asked.

Another tension I sometimes experience concerns religion. My view of religion is that I respect all religions and honor their traditions, even those traditions that are at odds with what I believe is fair and just. (For example, the rights of women and local minorities.)

One additional positive thing I have noted in my travels is that an activity that seems to bridge people around the world is technology, in particular the Internet. The access to facts and ideas that the Internet allows is enabling, and there is a common bond from rich countries to poor ones now that the Internet has become so ubiquitous everywhere on the planet.

While there is very little in the world that one individual can change, I will continue enjoying my travels around the world, especially in advancing the cause of improving health and healthcare through informatics. I will share both my knowledge and my attitude that when the right people are given the right tools, good outcomes can result.

Wednesday, March 18, 2015

Advice for Physicians in Training Seeking a Clinical Informatics Fellowship

Lately I have received requests for advice from physicians in training asking what they can do to make themselves more competitive for clinical informatics fellowship positions. In some sense these are similar to the emails I receive from established physicians asking about eligibility for the clinical informatics subspecialty here and now. To provide answers to the established physicians most efficiently, I prepared a blog post that I send them to as a reply to get them started in thinking about their eligibility. I am now doing likely in having a generic reply to physicians in training, and it is actually similar to another posting of mine from last year that provided advice to any young person seeking a career in informatics.

Let me then focus specifically on the physician in training who is considering pursuing formal training in clinical informatics, since I have increasingly been receiving emails with this question. My advice is really not much different from what anyone might advise a physician seeking training in any specialty or subspecialty. It is, however, important for potential trainees to remember that starting in 2018, fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME) will be the only pathway to achieve board certification in the new subspecialty.

As for advice, first and foremost, someone seeking formal training in clinical informatics should understand the field and its role in healthcare.  He or she should understand how informatics differs from information technology (IT), computer science, and related areas. The potential informatician should also be aware of the kinds of work that informatics professionals perform and the types of jobs into which they are hired.

A second critical piece of advice is to get involved in some informatics activity in their current medical school or residency program. It need not be a high-profile research project that gets published, but any activity that gives him or her an opportunity to perform and to be able to describe the application of informatics in a healthcare setting that provided value to someone, whether a physician, other healthcare professional, researcher, patient, or even a health system. While it would be ideal for the activity to be a medical school or residency rotation, it could also be volunteer activity. Whatever is done, he or she should be able to describe the work, who benefitted from it, and what principles of informatics it applied.

Another recommendation I can give is to become involved in some sort of professional organization or activity. While participating in a national organization such as the American Medical Informatics Association (AMIA) may be impractical, he or she can try to become involved in a local or regional organization. In Oregon, for example, we have an active local Health Information Management Systems Society (HIMSS) chapter. There are also national as well as local medical societies and other professional organizations that also carry out informatics activity.

A final bit of advice is to choose a fellowship that aligns with one's career goals. The clinical informatics subspecialty fellowship is focused on training for operational informatics work. Those more interested in a research career, especially if training in a medical specialty is not desired, should consider something like the National Library of Medicine (NLM)-sponsored research fellowships, which Oregon Health & Science University (OHSU) offers along with 13 other universities. Our clinical informatics subspecialty fellowship is just one of a family of educational programs in biomedical and health informatics offered by OHSU, and there might be other training options to consider.

In essence, those interested in clinical informatics should understand the field, get involved in it, and connect with professional associations. This advice is really little different from what one might advise someone seeking a career in almost any field. Such activity demonstrates a commitment to the field that will strengthen the application of someone who is seeking a fellowship in clinical informatics.

Sunday, March 15, 2015

Opportunity for Public Input into Evidence Report on Health Information Exchange

In the fall of 2013, I reported on a new project for which OHSU had been awarded a contract to carry out a systematic review of the evidence base for health information exchange (HIE). This project was funded under the Agency for Healthcare Research and Quality (AHRQ) Effective Healthcare Program. Our Department of Medical Informatics & Clinical Epidemiology (DMICE) houses one of the 12 Evidence-Based Practice Centers (EPCs) funded by the AHRQ to create evidence reports on a variety of healthcare topics.

I am pleased to report that the project is just about complete, and those who are interested in it can actually contribute. As is the case with all AHRQ evidence reports, a draft of the report has been posted for public comment. I encourage interested people to download the draft report and provide comments.

While there have unfortunately been two other systematic reviews to appear in the last few months [1,2], our report, based on AHRQ EPC protocols for evidence reports, will hopefully be more comprehensive and have used a more inclusive process. One of those processes is a period of public comment (simultaneous with formal peer review). The public comment period has just started and will be open until April 8, 2015. We look forward to constructive comments that will help improve the final report, which will be available in a few months.


1. Rudin, RS, Motala, A, et al. (2014). Usage and effect of health information exchange: a systematic review. Annals of Internal Medicine. 161: 803-811.
2. Rahurkar, S, Vest, JR, et al. (2015). Despite the spread of health information exchange, there is little evidence of its impact on cost, use, and quality of care. Health Affairs. 34: 477-483.

Thursday, February 26, 2015

Input to the Working Group to Chart the Future Course for the National Library of Medicine

Like many in academic informatics, my career has benefitted greatly from the support of National Library of Medicine (NLM), the institute of the National Institutes of Health (NIH) that has been devoted to, among other things, support for research and training in biomedical and health informatics. I have written over the years in this blog (in 2011 and 2014) of the myriad contributions of the NLM to biomedicine and health, including its unique role in funding basic research in informatics, especially clinical informatics.

The NLM has been guided over the past 30 years by a single leader, Dr. Donald AB Lindberg, whose vision and steady hand have led it to great success. Virtually everyone in healthcare has benefited from the NLM's successful initiatives that have been carried out during Dr. Lindberg's tenure, especially the information resources of Pubmed, MedlinePLUS,, and the myriad of genomics resources under the auspices of the National Center for Biotechnology Information (NCBI). Late last year, Dr. Lindberg announced his retirement. This has prompted the NIH to launch a working group and Request for Information (RFI) process to chart the future course of the NLM in advance of appointing a new leader.

Naturally, I view this opportunity as a chance to weigh in on the future of the NLM, which is so critical not only to my own work but also to the informatics field in general and really all of the healthcare enterprise. In the rest of this posting, I list the RFI questions in underline and then provide the answers I entered into the NIH site for collecting them. I look forward to seeing what others write as well as the final report of the working group. Appointing a leader to sustain Dr. Lindberg's contributions is one of the most essential actions for the NLM and the informatics field going forward.

(I do note that one of the challenges with the RFI structure is the lack of a section to make comment about the NLM with regards to all of its missions and constituents. As such, I have placed my comments more disproportionately in the section on the research community, since I believe the issues of basic informatics research are most important to be addressed in the transition to new leadership.)

Current NLM elements that are of the most, or least, value to the research community (including biomedical, clinical, behavioral, health services, public health, and historical researchers) and future capabilities that will be needed to support evolving scientific and technological activities and needs.

The NLM is a unique resource to all communities, especially the research community, in two areas: its basic research and education function in biomedical and health informatics and its library function. The NLM's library function is in excellent shape, and it continues to be an innovator and leader in its world-leading medical library function.

I have more serious concerns about the NLM's research function. Although there are many institutes within NIH (e.g., NCI, NHLBI, and the Fogarty International Center) and other entities outside of NIH (e.g., AHRQ and PCORI) that fund research in informatics-related areas, NLM is the only entity that funds basic research in biomedical and health informatics. Most of the other institutes and entities that fund informatics support projects that are highly applied and/or domain-focused. These projects are important, but basic informatics research is also key to improving both individual health as well as the healthcare system.

The NLM is also nearly unique in funding basic research in clinical informatics. A good deal of informatics research in the other NIH institutes is focused in basic science, e.g., genomics, bioinformatics, and computational biology. AHRQ and PCORI support clinical informatics research, but it is highly applied. Only NLM funds critical basic research in clinical informatics, and this function is vitally important as we strive to use informatics to achieve the triple aim of better health, improved healthcare, and reduced costs. Some of these areas of basic research include standards and interoperability, usability, workflow analysis, natural language understanding, and the intersection of people and organizational issues with information technology.

Informatics research within NIH and other government agencies is also very silo-ed. Why, for example, is the new Data Science (BD2K) program housed in the NIH Director's Office, when it really should be organized as a part of larger informatics science. (Indeed, many BD2K grantees, including myself, receive a good deal of their other research support from NLM.) Initiatives such as data science should really be part of an integrated approach to informatics research and be part of the NLM (or what the NLM should become).

A final critical function of NLM that has provided value and should be maintained is its training programs for those who aspire to careers in informatics research. I count myself among many whose NLM fellowship training led to a successful career as a researcher, educator, and academician generally. NLM training grants have also provided support for my university to educate the next generation of informatics researchers who have gone on to become successful researchers and other leaders in the field.

One part of the problem is that the name itself, "National Library of Medicine," does not connote all of what NLM does. Yes the NLM is a world-renowned biomedical library, and that function is critically important to continue. But NLM also provides cutting-edge research and training in informatics, and an ideal change for NLM would be a name change to something like the "National Biomedical and Health Informatics Institute," of which a robust and innovative National Library of Medicine would be a vital part.

Current NLM elements that are of the most, or least, value to health professionals (e.g., those working in health care, emergency response, toxicology, environmental health, and public health) and future capabilities that will be needed to enable health professionals to integrate data and knowledge from biomedical research into effective practice.

The NLM's library function is critical to all healthcare professionals, and this group probably benefits most from the NLM's excellent use of tax dollars in implementing its freely available resources. However, healthcare professionals have also benefitted from, and will likely continue to benefit from, NLM's basic research, especially in clinical informatics. While the adoption of knowledge systems, electronic health records, health information exchange, and other informatics applications has increased substantially in the last decade, the foundation for these applications emerged in no small part from NLM basic research in informatics. And as these applications are all far from perfect, they will likely need continued research to increase our understanding and optimization of them.

The success of the NLM's work has also led to a new category of health professional, which is the informatics professional, manifested most prominently in the area of clinical informatics. A growing number of healthcare provider organizations have established operational clinical informatics units, which are usually distinct from IT units. These are often directed by a Chief Medical Informatics Officer (CMIO). Another manifestation of this success is the designation of clinical informatics as a physician subspecialty. There are now 787 board-certifiied clinical informaticians, and a number of universities are establishing fellowship programs accredited by ACGME. In the meantime, AMIA has established an Advanced Interprofessional Informatics Certification process that will lead to certification of non-physicians in clinical informatics. These health professionals will play a vital role in applying the results of informatics research to innovating and improving patient care. This also gives impetus for maintaining a strong basic research effort in clinical informatics, and the NLM is uniquely poised to continue that role.

Current NLM elements that are of most, or least, value to patients and the public (including students, teachers, and the media) and future capabilities that will be needed to ensure a trusted source for rapid dissemination of health knowledge into the public domain.

The NLM's library function also ensures rapid dissemination of high-quality knowledge for patients and the general public. Its flagship site, MedlinePLUS, is a gold standard for high-quality, consumer-oriented health information. Of course, there are still a myriad of research issues about optimizing informatics for patients and the public. How do we insure the most appropriate information is delivered to such individuals at an appropriate depth and reading level? What is the role of personal health records in integrating knowledge and guidance? These research questions further demonstrate the importance of basic informatics research.

Current NLM elements that are of most, or least, value to other libraries, publishers, organizations, companies, and individuals who use NLM data, software tools, and systems in developing and providing value-added or complementary services and products and future capabilities that would facilitate the development of products and services that make use of NLM resources.

Likewise, the NLM's library function ensures rapid dissemination of high-quality knowledge for those who produce and disseminate information in the public and private sectors. The standards it sets provide interoperability unparalleled in other areas of the healthcare industry. In this area as well, the basic research of NLM is critical, contributing to more effective ways to produce and disseminate information in a vibrant marketplace.

How NLM could be better positioned to help address the broader and growing challenges associated with:

  • Biomedical informatics, “big data”, and data science;
  • Electronic health records;
  • Digital publications; or
  • Other emerging challenges/elements warranting special consideration.

The NLM, and the research it funds, is well-positioned to address all of these listed challenges.

Individuals who are trained in biomedical and health informatics not only understand Big Data and Data Science, but also bring the perspective of other aspects of informatics, such as standards and interoperability, usability, clinical workflow, and people and organizational issues. Data science transcends algorithms; it requires a thorough understanding of the quality and veracity of data. The understanding of how data, information, and knowledge are generated, organized, critiqued, and maintained is a unique skill of those who are trained in informatics. As noted earlier, the BD2K initiative should really be housed in the NLM, since it is part of larger informatics science and the fact that many who are funded by BD2K also have other funding from NLM.

The same applies to electronic health records (EHRs). While the HITECH Act has led to widespread adoption of EHRs, there are still many challenges associated with their optimal use. Basic research in clinical informatics established the foundation of modern EHRs that enabled companies such as Epic, Cerner, Allscripts, and others to thrive in the market. As such, continued research and training of researchers is necessary to ensure sustained progress, especially with the need to move to standards-based interoperable systems. The presence of academic research will also provide a bulwark against EHR development being driven solely by industry, which has an important role to play, but also requires basic research to push innovation in the market.

There are also emerging technologies, some of which we cannot foresee. When I was an NLM informatics postdoctoral fellow in the late 1980s, I could not have imagined the details of the World Wide Web, the wireless ubiquitous Internet, or modern mobile devices. There are likely new technologies coming down the road that few if any of us can predict that will have major impacts on health and healthcare. It is critical that the NLM and the research it supports enable these technologies to be put to optimal usage.