Training in Pathology Informatics: Lecture, Project, Rotation, Fellowship and beyond
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Transcript of Training in Pathology Informatics: Lecture, Project, Rotation, Fellowship and beyond
120 September 20101
Training in Pathology Informatics: Lecture, Project, Rotation,
Fellowship and beyond
Raymond D. Aller, M.D.Director of Informatics
USC Pathology
20 September 2010
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Acknowledgments Dozens have contributed – I can mention
only a few here Ramzi Cotran, Stan Robboy, Roger Cote,
Brad Copeland Frank Elevitch,Bill Hartmann,Tom Lincoln Mark Tuthill, Bob Miller, John Gilbertson,
Paul Catrou, Anil Parwani, Ul Balis Wes Naritoku, John Vallone, Alexis Carter, Stephen Hewitt, John
Sinard, Brian Jackson
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Evolution of training in pathology informatics
Explorers and pioneers: we have been training for a long time
Training in general medical informatics programs
Early adopters - OJT ABP: informatics as a subspecialty - Spotty coverage in residency Sporadic fellowships
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More recently, it gets better ...
Ongoing fellowships General medicine rediscovers board
certification Advertising for these skills
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The explorers
Bill Dito, Art Rapapport, George Brecher, Homer Warner, Phil Hicks, many others
Self taught From basic data management to deeper
analysis
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The pioneers
Mike McNeely, Don Connelly, Delane Wycoff, Art Krieg,
Again, focused on facilitating lab workflow Some – graduate degrees, MD theses,
NLM fellowships Both explorers and pioneers passed
knowledge to colleagues via national meeting seminars
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Informatics training: past
1970's: informal rotations, occasional masters and MD theses – Missouri, Utah, Minnesota, Harvard, others
1980's: under pathology leadership, NLM sponsored training fellowships at several universities – plus others
– NLM leader: Don Lindberg
– Ohio State: Jack Smith, Oregon: Bob Beck, Minnesota: Don Connelly, Utah: Stan Huff, Indiana: Clem McDonald
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National pathology meetings and resources
1970's on – Informatics seminars – ASCP, CAP, IAP (now USCAP)
1983: AIMCL, University of Michigan 1984: Bill Dito's Informatics in Pathology journal 1987: monthly pathology informatics coverage in
CAP Today (continues today) Late 1980's: over half of the seminars presented
at the biennial CAP meetings are on informatics.
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User Group meetings Another important source of lab informatics
training How to get more value out of a system you
already own How to get past seeming roadblocks to improve
patient care Many of the most relevant and practical seminars
are in this context E.g.: Sunquest, Kontron, Medlab, Mediware,
Meditech, Cerner, Soft
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Written Resources
For many years, there was only a single textbook in this field (Elevitch, ABCs of LIS)
Chapters in Henry Some journal articles CAP Today coverage In past five years, a number of useful books have
appeared
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“Just in time” knowledge
Calling your friends Local colleagues Google, Wikipedia, etc API listserv
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American Board of Pathology proposed subspecialty
1992 Letter of intent to American Board of Medical Specialties
Intended to be open to diplomates of any of the ABMS boards
Appointed 5-member informatics test committee
Test committee met for a number of years Unfortunately, could not devise a sufficient
number of questions testing informatics (as opposed to “bits and bytes”)
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Formal informatics training in pathology departments.
1993: the residency informatics rotation described
An increasing number of departments offer rotations
1980's-1990's: A few unique fellowship trainings – Johns Hopkins, Michigan
CAP Foundation training grants – for residents to attend AIMCL, APIII
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Into our own – the 2000's
A number of formal fellowships established, fellows trained
The Association of Pathology Informatics Description of curriculum for a fellowship At end of decade: a few fellowships fully
active, but others lack sufficient candidates
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How is informatics information available to pathologists today?
National meetings: CAP, USCAP, AABB, DR/EWC, AACC, ASM, CLMA, PI2010
National LIS user's groups CAP Today Occasional articles in other path journals Articles in general informatics journals Most recently: online J Path Informatics Residency training in informatics required Fellowships
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Residency rotations lacking
Many departments/programs lack interested faculty
In some departments, informatics does not get academic respect
Competition for time in the general residency training
We know how to teach surgical pathology – we are still learning how to teach informatics
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Compensating for inadequate training
Residents fail to recognize the gap in informatics training until too late.
Some apply for CAPF travel grants to attend LabInfoTech, APIII, Pathology Visions, or now PI2010.
Others don't do even that much. Very few seem to take advantage of
rotations available in other programs, with strong informatics faculty
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Leaving value on the table ...
One program with a well established informatics curriculum and faculty offered a rotation for residents from other programs - yet over a number of years, no one applied or came.
While residents seem to understand the need for slide-reading skill, they seem clueless about managing the actual product of their department.
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Pathologists without basic understanding
Recent training is no defense Many residencies lack a meaningful
rotation National pathology meetings offer fewer
informatics seminars than they did 15 years ago.
National meeting seminars: they gave a party, no one came...
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Most fellowships are under-subscribed
One university offered a fellowship, it was never filled
Another only had four fellows in 25+ years
Others are less than half full.
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Program began trained so far
concurrent
duration
advance admiss
faculty
Pitt 2000 15 1 1 16 2+6
MGH/Part 2007 2 5 1 to 2 16 14
Henry Ford
2006 2 1 2 4 1
Johns Hopkins
1990 4 1 1 to 2 4 1
Michigan 95/08 3 1 2 4 55
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Length of the fellowship
Some programs structured as one year, others as two years
One year: – less time away from other aspects of
pathology practice– May be easier to schedule
Two years:– More time for fellow to learn the environment,
become a productive member of the team– “Informatics projects are at least two years”
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Thoughts on structure: 2 years
Gives a better chance for the fellow to become a productive (net-positive-FTE) member of the team
Lead time on position recruitment may be 18+ months
Strongly consider including a component of case-based responsibilities
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Case-based responsibilities
Such as a rotation reading biopsies - within the informatics fellowship.
– to prepare our fellows for practice settings, and
– to maintain continuity with case-based pathology
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Thoughts on background: 1 year
For those who already have leadership and management skills (may have been in practice for some years)
Desire greater depth in informatics than afforded by their (non-)rotation in residency.
How do we ensure that they come up to speed more rapidly, and take on adequate front-line responsibility?
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More concerns about 1-year fellowships:
Not long enough to learn the systems and people, to become productive, and to have an impact.
Not enough time to develop skills; yes it gets them out and they can start earning, but they are very green; mainly this relates to a mature perspective and business management and negotiation skills
Both MGH and Henry Ford noted 2 years is just barely enough time to develop skills
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How far in advance are fellows appointed?
The more successful and highly subscribed programs designate the next fellows about 15 months in advance.
In order to compete for candidates 18-24 months in advance, funding must be secure a long time ahead
Otherwise, the best candidates have already committed to another program before the less-funded program can even offer a slot.
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Those programs recruiting later ..
... recruit only a few months before the program would begin.
However, the best candidates are making a commitment for a period 18 months through 42 months from now.
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Facilitator/administrative support
Half time, or so The two most successful/highly
subscribed fellowships each have such a support person
It appears that the others (less successful in recruiting) do not have such support.
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How many faculty?
.. at least 40% time doing informatics (service, research, teaching, etc)
One, one, two, two + six, 5, 14
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Faculty roles
Program leader/director/cheerleader Plus additional staff with special interests:
imaging , Adjunct contributors for management,
regulatory, Co-directors in CP, AP, molecular,
imaging
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Number of fellows -
Many programs - zero much of the time
Some programs, one
Another, five
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Funding
To assure continuation of program To increase the number of fellows To provide additional support for faculty
(e.g., NLM training grant at Pitt)
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Funding sources
-- Intramural/practice funds
– Laboratory revenues
– NIH training grants of various types
– One program mentioned growing beyond the current 5 - "could easily recruit and train 6 or more fellows next year"
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Consistent funding
Essential to carry forward with such a fellowship (can't recruit otherwise)
Some fellowships have been hamstrung by inconsistent funding
However, it is often challenging to justify existing front-line operational employees in the informatics group - the linkage between funding and productivity of an informatics fellow may be more difficult
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General medical informatics programs
Interaction with NLM funded general medical informatics fellowship?
MGH - available, but not best option Some others – not available
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Making the fellowship sustainable: not just funding
How to reach the point where faculty time consumed is more than made up by useful work product of the fellows.
How do we get fellows up to a point where they can begin to do things independently (need to acquire a deep understanding of existing systems)
“I just don't have any "excess" time to spend with a fellow.”
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Impact on faculty time
“our current fellows are experienced, all three have prior experience with operations and research. They are a net positive”
“it's nearly a wash year one; very valuable year two”
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Avoiding faculty overwhelm
Recruit candidates who already have management/leadership skills
If you offer a 1-year fellowship, bring in people who can already contribute
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Effect on faculty workload
Faculty time
Weeks -->
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Subjects covered in fellowships
Management and workflow optimization Administrative-type activities with the
informatics group However, avoid "just follow me around to
meetings" Image management, analysis, image
perception Molecular epidemiology Health services research
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Programming?
Understanding the use of tools is essential, but it doesn't teach pathology informatics
for a person who already knows programming, to simply do another programming project is not productive.
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Operational responsibilities
"depends dramatically on their career goals and their experience" vs.
“Essential for a training program” Developing new tools and approaches Implementing systems Innovative pathology reporting (online,
graphical, interactive) Web-based delivery of diagnostics
information
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Fellowship projects
Large clinical operations projects that involve the health system and the lab
many! as many as possible; big, small; part of team;
goal is to get them to lead a large to medium size department project of their own with budget, staff, planning etc.
The topics are matched to the fellows interest and skills
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Ideas for projects
may originate from their own idea; more typically related to labs needs and
established plans. As projects require capital and resources these
just don't pop up and get done.
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Informaticists should use what they develop
In one case, a clinical pathologist “C” developed a cytology system for his colleagues – they seemed to think it was fine
Several months later, one of the partners became ill, and C was asked to take a rotation on signing out Paps
C soon realized that the system's workflow was awful
He fixed it, and his colleagues agreed it was much improved.
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Implications: informatics practice Some program directors commented on
the jobs their fellows had taken Spending 50% time in informatics, and
50% time in a more traditional subspecialty, has several advantages
Not only are systems better designed, but you have more credibility if you share in the “workload”
More opportunity for interaction with clinician colleagues if part of your time is in a case-based practice.
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Research time. Academic: 35-70% of time is protected
research time, depending on goals. Related: opportunity to earn a graduate degree (MS, Ph.D.)
Community -they have "research projects" and studies they get involved in. Our shop is very operational. I consider what they do more proving concepts or testing solutions versus hypothesis driven research
For the pathologist interested in the community practice of informatics, time spent on research means less time learning the practicalities of informatics
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Service work
Myriad: – system maintenance,
– issues resolution,
Training of staff and residents No on call per seImage analysisDiagnostic pathology (e.g., surgical
pathology, cytopathology)Clinical pathology (e.g., transfusion medicine)
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A different type of disease
The surgical pathologist diagnoses a series of patient diseases
the informaticist
– diagnoses and treats the diseases of systems
– Finds ways to make work more efficient for his/her colleagues
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How do we teach
Responsibility
– How do we structure our organization so that the fellow has clear operational responsibility?
Leadership: informatics has much in common with management – both are difficult to teach to residents, fellows
Delegate the various tasks
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After fellowship ....
What are the next career steps for a pathologist after fellowship?
Several: academic medical centers
Another director of lab informatics at a large hospital in India
Some full time informatics,
more are half time informatics, half-time surgical pathology/etc.
At least one has founded own company
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Creation of new fellowships?
Talked with at least four organizations that are considering starting a fellowship:: academic, government, reference lab,
And with one well-established department that doesn't think it's feasible
Why create a fellowship?– General clinical informatics is thinking about
board certification – need to be at the table– Recognize the need for informatics leaders
in many organizations
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Barriers to creating a fellowship Faculty time Funding Facilitator (support person) Finding qualified people
• Very very small candidate pool • only one or two qualified
candidates per year" Fifth wheel (Finding a role) Free space F ......
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Lack of qualified candidates Not enough exposure in medical school, or
residency– Lack of training– Lack of mentors/examples
Most residents have no concept of informatics practice
Inconsistent funding for positions – year to year, soft money, or dependent on vagaries
Informatics fellowships are not ACGME-accredited
Uncertainty about job prospects – marketability Some applicants seem to want to hide in a
backwater
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ACGME accreditation? But there isn't an approved sub-specialty... Two types of programs accredited
– Regular subspecialty: transfusion medicine, chemical pathology, microbiology, etc...
– Selective pathology fellowships - over 60 of them• Many in special areas of surgical
pathology• A few in clinical pathology• This is the area where we would apply for
accreditation of an informatics fellowship
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ACGME accreditation for fellowships Advantages:
– Medicare funds ½ FTE– Time in fellowship counts towards
AP/CP Board time– Time counts toward maintenance of
certification How do we sign up?
– Pathology Residency Review Committee: program completes and submits the Program information form
– RRC evaluates the program, evaluates the quality of the teaching.
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Accreditation – a mixed blessing?
One large program: "don't think this would be a good thing"
A smaller program: don't really want the paperwork hassle; it is enough to comply with our own non-accredited fellowship requirements in the institution.
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Accreditation 2
- If board recognition became a reality for fellows, that might be a reasonable trade.
- “I just saw the 75 pages of &%$ our cytopath fellow had to submit to the ACGME. Major waste of time that had no impact on what fellows do now versus what they did ten years ago”
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Job prospects?
There are ads for pathologist informaticists – but not oodles of them
In many cases over the decades, informatics jobs have been created (perhaps from something else) when a candidate appeared
In other cases, a pathologist in a different role has evolved into the informatics role
Even advertised positions sometime specify a combination of skills that fit only one person in the country
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Some not optimistic
“Although I believe there should be more jobs available, especially as some of us older guys retire, and the perceived need, at least by API members, seems to be growing, I'm not sure those jobs will be supported. (Locally, when I retire, I really doubt if my position will survive).”
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Not optimistic 2
Hospital IS wants to absorb the LIS which I have fought to keep in Pathology for the last 20 years.
I think Pathology may have lost the ability to win the battle of ownership of pathology informatics. Hopefully, I'm wrong.
Currently, I sense a resurgence of energy to get pathology informatics back under pathology.
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Informatics plus another subspecialty
Maybe one idea should be to emphasize pathology informatics not only as a primary field, but also as a secondary field of emphasis when recruiting residents (eg, surg path/informatics, hemepath/informatics, molecular/informatics, etc).
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Trailblazers, pioneers, settlers "Today's pathologists who work in imaging
and data are like trailblazers, and the fellows will be the earliest settlers, but it will remain a rough world out there for a while, before things develop. I think the trailblazers enjoy the "risk", but I am not certain fellows appreciate that there are not jobs with pathology informatics as a job description/title out there yet."
In 50 years, we will be suburbanites
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What are candidates interested in?
“Recently, have seen increased interest from people that want to be directors of core labs.”
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General medical informatics programs
In some organizations, pathology informatics faculty spend their time with a general medical informatics group
Examples: Utah, Oregon, Johns Hopkins, Ohio State
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Advice to a department considering offering a program
O: “Ramp up your faculty and your department pathology informatics initiatives first, the fellowship will follow naturally.”
R: “plan: money, space, time and faculty; be aware that qualified candidates may not surface”
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Adding informatics into other fellowships
There may be opportunities to modify a traditional (e.g., surgical pathology) fellowship year to include a high component of informatics.
– During the elective months
– And as ongoing responsibility during the case-based months
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References
There are several useful articles on this topic in the literature.
Rather than trying to jam them on several slides, I ask that you eMail me to request a list
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Thank you!
I appreciate your attention raller @ usc.edu
I welcome your questions