WhatisBiomedicalInformatics?

WilliamHersh,MD,FACP,FACMIProfessorandChair

DepartmentofMedicalInformatics&ClinicalEpidemiologyOregonHealth&ScienceUniversity

Portland,OR,USAEmail:hersh@ohsu.eduWeb:www.billhersh.info

Blog:http://informaticsprofessor.blogspot.comTwitter:@williamhersh

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1

WhatisBiomedicalInformatics?

WilliamHersh,MD,FACP,FACMIProfessorandChair

DepartmentofMedicalInformatics&ClinicalEpidemiologyOregonHealth&ScienceUniversity

Portland,OR,USAEmail:hersh@ohsu.eduWeb:www.billhersh.info

Blog:http://informaticsprofessor.blogspot.comTwitter:@williamhersh

1

Outline

• Termsanddefinitions• Recentgrowthandchange– HITECHandmeaningfuluse

• People• Resources• Educationandtraining

2

2

Whatisbiomedicalandhealthinformatics?

• IgetaskedthissooftenthatIkeepaWebsite– http://www.billhersh.info/whatis/

• Andablog– http://informaticsprofessor.blogspot.com

• Ihavealsowrittenarticlesaboutit– Medicalinformatics:improvinghealthcarethroughinformation

(Hersh,2002)– Buttherearebarriers(Hersh,2004)– Characterizationofandchangesintheprofession(Hersh,2006)– Manycareeropportunitiesaswell(Hersh,2008)– Reconcilingdefinitionsofterms(Hersh,2009)– Theinformaticsprofessionalworkforce(Hersh,2010)– Clinicalinformaticsinthecontextofhealthsystemsscience(Hersh,

2017)

3

Otherviews• Earlydefinition:“storage,acquisition,anduseofinformation”(Greenes,1990)

• Other(US)perspectives– “Thescienceofinformationappliedtobiomedicine…dataplusmeaning.” (Bernstam,2010)

– Paradigmshiftinbiomedicinefrom“individualbrainstosystemsofbrains” (Stead,2011)

– AMIA:“Theinterdisciplinaryfieldthatstudiesandpursuestheeffectiveusesofbiomedicaldata,information,andknowledgeforscientificinquiry,problemsolving,decisionmaking,motivatedbyeffortstoimprovehumanhealth”(Kulikowski,2012)

• Europeanandglobalperspectives(Haux,2010;Hasman,2011;Geissbuhler,2011)

4

3

Letusstartbydefining“informatics”

• Thedisciplinefocusedontheacquisition,storage,anduseofinformationinaspecificsettingordomain(Hersh,2009)– Ismoreaboutinformationthan

technology• Sometimesdefinedasactivity

attheintersectionofpeople,information,andtechnology

• Thescienceof“sociotechnicalsystems” (Coiera,2007)

5

(SUNYBuffalo)

Whatinformatics“isandisn’t”(Friedman,2012)

• Is– Cross-trainingwherebasic

informationalsciencesmeetabiomedicalapplicationdomain

– Relentlesspursuitofassistingpeople

– Towerofachievement• Modelformulation• Systemdevelopment• Systemimplementation• Studyofeffects

• Isn’t– Scientistsorclinicians

tinkeringwithcomputers– Analysisoflargedatasets

perse– Circumscribedrolesrelated

todeploymentofelectronichealthrecords(*pointofdisagreement)

– Professionofhealthinformationmanagement

– Anythingdoneusingacomputer

6

4

Ithasa“fundamentaltheorem” anda“goldenrule”

7

FundamentalTheorem(Friedman,2009)– basedon“relentlesspursuitofassistingpeople”

Goalofinformaticsis

Goalisnot

GoldenRule(Kuperman,personalcommunication,2013):

“Neverimplementuntoothersthatwhichyouwouldnotimplementuntoyourself”

Mycurrentpreferredterminology• Biomedicalandhealthinformatics(BMHI)isthefieldconcernedwiththeoptimaluseofinformation,oftenaidedbytechnology,toimproveindividualhealth,healthcare,publichealth,andbiomedicalresearch– Informaticsappliedinamorefocuseddomainis{X}informatics,e.g.,nursing,dental,pathology,primarycare,etc.

– Canbeclassifiedby“level” ofdomainbutalsohassomeoverarchingareas,e.g.,imagingandresearch

• PractitionersofBMHIareusuallycalledinformaticians (sometimesinformaticists)

8

5

Informaticsalsohasan“adjectiveproblem”

(Hersh,2009;adaptedfromShortliffe,2006)

Informatics=People+Information+Technology

BiomedicalandHealthInformaticsLegalInformatics Chemoinformatics

Bioinformatics(cellularandmolecular)

Clinical(orMedical)Informatics

(person)

{Clinicalfield}Informatics

PublicHealthInformatics(population)

ConsumerHealthInformatics

ImagingInformatics ResearchInformatics

9

Informaticsnowviewedasacorecompetencyforhealthprofessionals

• AccordingtoInstituteofMedicinereport,themodernhealthcareprofessionalmusthavecompetencyininformaticsaspartoflargergoaltoprovidepatient-centeredcare(Greiner,2003)

• Informaticscompetencyisnotjustcomputerliteracy!– The“Googlegeneration” does

notnecessarilyhavegoodinformationskills(CIBER,2008)

• Informaticsisacorecomponentofthe“learninghealthsystem”(Friedman,2010;Smith,2012)

10

6

Somehistoricalperspectiveoninformatics

• OriginoftermattributedtoDreyfusin1962(Fourman,2002)

• AchievedwidespreaduseinFrance(informatique),Russia,andlaterrestofEuropein1960stodenotecomputingissuesrelatedtoinformationuse

• “Medicalinformatics” firstusedin1974(Collen,1994)– MoreEuropeanhistoryfromMoehr (2004)– HistoryoffielddocumentedbyCollen(1995,2015)

• Atpresent,mostsignificantuseisinbiomedicalarena,butitisusedbyotherdomains,suchaslaw,chemistry,socialsciences,etc.

11

Howisinformaticsdistinguishedfromrelatedterms?

• Informationtechnology(IT)– computerandrelatedtechnology

• ComputerscienceisacademicdisciplinethatunderliesIT(andothertechnologies)

• ManagementinformationsystemsisanotherfieldunderlyingIT(usuallyinbusinessschools)

• Healthinformationtechnology(HITorhealthIT)– health-relatedapplicationofIT

12

7

Otherrelatedterms

• Healthinformationmanagement(HIM)–disciplinehistoricallyfocusedonmanagementof(paper)medicalrecords(changingincurrentenvironment),withthreemainlevelsofpractice– RegisteredHealthInformationAdministrator(RHIA)–highestlevel,baccalaureatedegree

– RegisteredHealthInformationTechnologist(RHIT)–associatedegree

– CertifiedCodingSpecialist(CCS)– usuallylessthenassociatedegree

13

Otherrelatedterms

• Informationandcommunicationstechnology(ICT)– sameasITwithaddedemphasisontelecommunications

• eHealth – useofICTforhealth• Telemedicine – provisionofhealthcarewhenparticipantsseparatedbytimeand/ordistance

• Telehealth – pursuitofhealthwhenseparatedbytimeand/ordistance

• mHealth – useofmobiledevicesforhealth

14

8

Otherrelatedterms• Evidence-basedmedicine(EBM)– theapplicationofthe

bestscientificevidenceinthemedicaldecision-makingprocess

• Evidence-basedpractice(EBP)– theapplicationofEBMinclinicalpractice

• Comparativeeffectivenessresearch(CER)– researchthatcomparesoneormorediagnosticortreatmentoptionstoevaluateeffectiveness,safetyoroutcomes(alsocalledpatient-centeredoutcomesresearch)

• Informationretrieval(alsoknownassearch,partoflargerknowledgemanagement)– thefielddevotedtosearching(mostlytext,mostlyknowledge-basedinformation)

15

Termsrelatedtomedical/clinicalrecords

• Electronichealthrecord(EHR)– patient’shealthrecordindigitalform– Hasmostlysupplantedelectronicmedicalrecord(EMR)

• Meaningfuluse– programofincentivesforEHRadoptioninUSrequiringthattheybeusedinwaysthatachievehealthcaregoals

• Personalhealthrecord(PHR)– personallycontrolledhealthrecord

• Healthinformationexchange(HIE)– exchangeofhealthinformationacrosstraditionalbusinessandotherboundaries(averb)– OrganizationmanagingHIEusedtobecalledaRegionalHealth

InformationOrganization (RHIO),nowcalledanHIE(anoun)

16

9

KeyaspectsoftheEHR

• Therecordanditsdata• Standards andinteroperability• Meaningfulusethroughclinicaldecisionsupport(CDS)andcomputerizedphysician/providerorderentry(CPOE)

• Implementationandevaluation• Privacy,security,andconfidentiality• Re-use(orsecondaryuse),includinganalytics,ofdata

17

ManyareextollingthevirtuesofBMHIinhealthcareandrelatedareas

• Mostprominentdiscussionhasfocusedonimprovinghealthcarethroughimprovedquality,safety,andefficiency

• However,therearemanychallenges– MixingITwithclinicalworkflowhasbeendifficult– SomeHIThasbeendeleterious– FinancialbenefitsofITdonotalwaysaccruetothosewhopay

– Largerproblemsinhealthcareorganizationandfinancingmakeanytypeofchangedifficult

18

10

Informaticsisalsoessentialformodernbiomedicalresearch

• EmbodiedintheNationalInstitutesofHealth(NIH)Roadmaptoacceleratebiomedicalresearchdiscovery(http://commonfund.nih.gov)– Today’sbiomedicalresearcherroutinelygenerates…billionsofbytesof

data.…Whatresearchersneedarecomputerprogramsandothertoolstoevaluate,combine,andvisualizethesedata.Insomecases,thesetoolswillgreatlybenefitfromtheawesomestrengthofsupercomputersorthecombinedpowerofmanysmallermachinesinacoordinatedwaybut,inothercases,thesetoolswillbeusedonmodernpersonalcomputersandworkstations.

• AlsopermeatesprioritiesofNIHDirector(Collins,2010)– High-throughputtechnologies– Translationalresearch– Supportinghealthcarereform– Globalhealth– Empoweringtheresearchcommunity

19

Informaticstermsforbiomedicalresearch

• Translationalresearch– classically,thetranslationofbasicresearchintoclinicalapplicability(“benchtobedside”),butalsofromcontrolledsettingstocommunityandpopulation(Woolf,2008)– Increasingrecognitionthatresearchfindingsmust“translate” intoclinicalcare

morequicklyandefficiently,leadingtoUSgovernmentinvestmentinclinicalandtranslationalresearchthroughtheNIHClinical&TranslationalScienceAward(CTSA)program(Leshner,2013)

– Translationalbioinformatics– bioinformaticsappliedtohealth-relatedproblems(Kann,2013)

• Precisionmedicine (IOM,2011;Collins,2015)– clinicalcaretailoredtoanindividual’scharacteristics,includingtheirgenome– Sometimescalledpersonalizedmedicine(Schleidgen,2013)

• Clinicalresearchinformatics(CRI)isareaofinformaticsappliedtoclinicalresearch(Richesson,2012)– Differencebetweeninformationtechnology(IT)andinformaticsvery

evidentinthisdomain(Bernstam,2009)

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11

Wecannotignoretheessentialroleoftheconsumer/patient/citizen

• OriginalStrategicFrameworkoftheOfficeoftheNationalCoordinatorforHealthIT(ONC)calledforITtofacilitate“consumer-centric,information-rich” healthcare(Brailer,2004)

• SomeadvocatethatthePHRbeatthecenterofthediscussionconcerninghealthrecords(Krist,2011)– Manyissuesrelatedtoflowofinformationandresponsibilityfor

it• e-Patients – Internet-enabledpatients

– Originatedwithself-helpleader,Dr.TomFerguson(2007)– Bestknownise-PatientDave,whofoundagreatdealof

incorrectinformationinhismedicalrecordinBostonteachinghospitalandpublicizeditwidely(Wangsness,2009)

21

Afinalperspectiveofinformatics• Dataè Informationè Knowledge

– UsedinmanyfieldsbutintroducedininformaticsbyBlum(1984)

• Dataaretherawmaterialcollectedandstored• Informationgivesmeaningandorganizationtothedata

• Knowledgeprovidesunderstandingandapplicabilitytonewsituations

• Someaddwisdom,asknowinghowtoapplyknowledge(Rowley,2007)

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12

Informaticsisincreasinglybecominga“datascience”

• EHR(andprobablyallinformatics)workchangingfrom“implementation”to“analytics”(Hersh,2012)

• Datascienceisthe“sexiestjobofthe21stcentury?”(Davenport,2012)

• Growingimportanceofroleforanalytics inhealthcare(Adams,2011;O’Reilly,2012;Hersh,2014)– Butwemustusecautiontomakesurethatclinicaldataiscomplete,correct,andotherwisesound(theroleofinformatics?)(Hersh,2013)

23

Wehaveenteredtheeraof“BigData”

• Four“V’s”ofBigData:volume,velocity,variety,andveracity(Zikopoulos,2011)

• Leadingtoanewparadigmofscience(Hey,2009)?– Makingthescientificmethodobsolete,i.e.,noneedfor

experimentationanymore?(Anderson,2007)– Notreally;manycaveatsforresearchuseofclinicaldata(Hersh,

2013)• OtherconcernsaboutdatascienceandBigData

– “Provocations”tostudyingdata(Boyd,2011)• Biggerisnotnecessarilybetter• Westudywhatwecananswer• Notalldataisavailableoraccessible

– Haven’tmanyfieldsbeendoingthisalready,e.g.,statistics(Donoho,2015)?

24

13

Ismedicine/healthreallyaninformationscience?

• Timestudiesofhospital(Ammenwerth,2009;Tipping,2010;Kim,2010;Tipping,2010;Yousefi,2011;Victores,2014)andemergency(Chisholm,2011)physiciansshowphysiciansspendabout– 15-38%oftheirtimeindirectpatientcare– 50-67%oftheirtimeinindirectpatientcare,dividedbetween

reviewingresults,performingdocumentation,andengagingincommunication

• Studiesofoutpatientphysiciansfind– 14-39%ofworktakesplaceoutsidetheexamroom(Gilchrist,

2005;Gottschalk,2005)– Workrelatedtopatientwhenhe/shenotpresentconsumes15-

23%ofphysicianworkday(Gottschalk,2005;Farber,2007;Chen,2010)

25

Evenmoreworkwithdataandinformationmorerecently

• StudiesineraofwidespreadEHRadoption– Internsinlightofdutyhoursrestrictionsfoundtospendlesstimein

directpatientcareandmoreintalkingwithotherphysiciansanddocumenting,withabout40%oftimespentinteractingwithcomputers(Block,2013)

– About60%ofinternistsreported“loss”ofaround48minutesperdayduetoEHRusage(McDonald,2014)

– Residentsinanacademicteachinghospitalfoundtospend50%oftimewithcomputersvs.10%timedirectlywithpatients(Mamykina,2016)

– PhysiciansfoundtospendtwohoursoftimedoingEHRanddesktimeforeveryhourofdirectpatienttime,plusanadditional1-2hourspernight(Sinsky,2016)

• Thesestudiesdon’tanswerwhatistherightamountoftime(Hersh,2013)

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14

Pause

• Turntoyourneighboranddiscussoneofthefollowing– Describeactivityinyourworkthat

• Isinformatics• Isnotinformatics

– Doeshealthcaresystemnowspendtoomuchtimewithcomputers?

• Iwillaskforafewtovolunteeranswerstooneofthetwoquestions

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Informaticshasgonefrom“dot-com”to“dot-gov”(Kleinke,2007)

• BushAdministration– Recognizedvalueofhealthinformationtechnology(HIT)– Actions:OfficeoftheNationalCoordinatorforHealthIT(ONC),AmericanHealthInformationCommunity(AHIC),etc.

• ObamaAdministration– TheAmericanRecovery&ReinvestmentAct(ARRA)of2009providedincentivesfor“meaningfuluse”ofelectronichealthrecords(EHRs)andtheinfrastructuretoachieveitthroughprovisionsoftheHealthInformationTechnologyforEconomicandClinicalHealth(HITECH)Act(Blumenthal,2011;Blumenthal,2011)

28

15

TheBushAdministrationstartedpromotionofthefield

• PresidentBushStateoftheUnion– mentionedeveryyearfrom2004to2008– January,2004– “Computerizinghealthrecords[can]reducecosts,improvecare,andlowertheriskofmedicalmistakes.”

– January,2007– “Weneedtoreducecostsandmedicalerrorswithbetterinformationtechnology.”

• Bushalsosetgoalofelectronichealthrecords(EHRs)forhalfofallAmericansby2014(WhiteHouse,2005)

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TheObamaAdministrationuppedtheante

“Toimprovethequalityofourhealthcarewhileloweringitscost,wewillmaketheimmediateinvestmentsnecessarytoensurethatwithinfiveyears,allofAmerica’smedicalrecordsarecomputerized…Itjustwon’tsavebillionsofdollarsandthousandsofjobs– itwillsavelives.”

January,2009

16

OtherUSgovernmentagenciesandentitiesinvolvedinhealthIT

• NationalLibraryofMedicine(NLM,www.nlm.nih.gov)andotherinstitutesoftheNationalInstitutesofHealth(NIH)– NLMleaderinfundingresearchandtrainingininformatics– ReaffirmedwithappointmentofnewleaderandincorporationofNIHdata

scienceactivities(Brennan,2016;Brennan,2016)• AgencyforHealthcareResearch&Quality(AHRQ,www.ahrq.gov)

– Fundsresearchandpolicydevelopment,produceshealthITinformationresources

• CentersforMedicareandMedicaidServices(CMS,www.cms.hhs.gov)– Payor forMedicareandMedicaid,includingHITECHincentives

• NationalCommitteeforVital&HealthStatistics(NCVHS,www.ncvhs.hhs.gov)– Governmentadvisoryboard,includingissuesrelatedtohealthIT

31

TheObamaAdministrationledusintoanew“ARRA”ofhealthIT

• Viewedbysomeasa“downpayment”onhealthcarereform

– ARRAincludedtheHITECHAct– Incentivesfor“meaningfuluse”ofEHRsbyphysiciansandhospitalsstartingin2011(upto$27B)

– Directgrantsadministeredbyfederalagencies($2B)– AlsoHIT-relatedprovisionsinotherareasofARRA,e.g.,

• Comparativeeffectivenessresearch• NIHandotherresearchfunding• Broadbandandotherinfrastructurefunding

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17

ONCenhancementsduringObamaAdministration

• AppointedDr.DavidBlumenthalasthirdNationalCoordinatorforHIT– Awell-knownHarvardhealth

policyleaderwithinformaticsresearchcredentials

– LedinitialimplementationofHITECHAct(Blumenthal,2011;Blumenthal,2011)

– Followedbysubsequentothers– Currentstrategicplan(2015)

• “PuttingtheI inHealthIT”–www.healthit.gov http://www.healthit.gov/policy-researchers-

implementers/health-it-strategic-planning

Whatis“meaningfuluse?”

• Conceptintroducedinthe2007-2008Congress,HR6898:Health-eInformationTechnologyActof2008butnotpassedatthattimebyStark(2011)

• ItisnotenoughtouseEHRsbutmustusetheminmeaningfulwaystoachievegoalsofhealthcaresystem• Achievingcriteriatiedtofivegoalsforhealthcare• EHRsmustbecertified,abletoexchangeinformation,andabletoreportonclinicalqualitymeasures

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18

HITECHinfrastructure

• http://www.healthit.gov/policy-researchers-implementers/health-it-adoption-programs

• HITRegionalExtensionCenters(RECs)– $677milliontofund62RECsthatprovideguidance,mainlytosmallprimarycarepracticesandcriticalaccesshospitals,inachievingmeaningfuluse(Maxson,2010)

• State-basedhealthinformationexchange(HIE)– $547millioningrantstostatestodevelopHIEprograms

• Workforcedevelopment– $118millionfor– Communitycollegeconsortia($70M)– CurriculumDevelopmentCenters($10M)– Competencytesting($6M)– University-basedtraininggrants($32M)

35

HITECHinfrastructure(cont.)• StrategicHealthITAdvancedResearchProjects(SHARP)Program– stillaneedforresearch;$60Mforfourcollaborativeresearchcenters– SecurityandHealthInformationTechnology– Patient-CenteredCognitiveSupport– SecondaryUseofEHRInformation– HealthCareApplicationandNetworkDesign

• Mostperseveringofthese,hasledtotheSMARTframework(Mandl,2012)

• BeaconProgram– shiningthelightforwardwith$250Mfunding17advanceddemonstrationprojects(Maxson,2010;McKethan,2011)

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19

Thereisstillplentyofroomforfree-marketeers

• HITindustryestimatedtoreach– $228Boverallgloballyby2020,with13.4%annualgrowthrate

(Markets&Markets,2015)– $84Bformobilesolutionsgloballyby2020,with28.4%annual

growthrate(Markets&Markets,2015)– $18.7Bfordataanalyticsgloballyby2020(Markets&Markets,

2015)• Manyinvestmentactivities,e.g.,

– RockHealth– http://rockhealth.com– NewYorkDigitalHealthAccelerator–

http://digitalhealthaccelerator.com– MassachusettsDigitalHealthInitiative–

http://massdigitalhealth.org– CambiaGrove– www.cambiagrove.com

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HITisnotlimitedtotheUnitedStates

• England– NHSConnectingforHealth– Mostambitiousinworldbutultimatelyfailedafterspending$18billionfor

developingnationwideEHRsandHIE(Brennan,2007;Hayes,2008;Payne,2011;NHS,2011)

– Morerecentapproachesbasedonscaled-backgoals(Wachter,2016)• Denmark

– Near-universaladoptionofEHRsandothertechnologies(Protti,2010)• CanadaHealthInfoway

– http://www.infoway-inforoute.ca/• SingaporeNationalEHR(Accenture,2012)

– https://www.moh.gov.sg/content/moh_web/home/Publications/educational_resources/2015/national-electronic-health-record--nehr-.html

• Argentina(Quiros,2009)• AustraliaMyHealthRecord

– https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/content/home

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20

UShasbeenalaggardbutisnowcatchingup

39

(Osborn,2015)

(Henry,2016)

Informaticsalsorequiresustoaddressharmsandlimitations

• IOMHITsafetyreportdocumentedconcernsaboutdangers(2012)

• Keyissuestoaddressareworkflow(Carayon,2010)andusability(Lowry,2012)

• EHRmustmovefrombeingamonolithic,transaction-basedapplicationtoaplatform(Glaser,2012;Mandl,2012)

• HasEHRunderminedmedicineorarewein“transitionalchaos”(Rosenbaum,2015;Martin,2016)?

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21

Pause

• Turntoadifferentneighboranddescribeactivitiesinyourworkthat– Showedthebenefitofinformatics– Showedsomeharmfrominformatics

• Iwillaskforafewtovolunteertheiranswers

41

Whodoesbiomedicalandhealthinformatics?

• Opportunitiesfortheinformaticsworkforce• Whatweknowaboutthehealthinformationtechnology(HIT)workforce

• Whatweknowaboutinformaticsleaders• Educationandcertification• HITsalaries• Informaticscompetenciesforinformaticiansandnon-informaticians

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22

Opportunitiesfortheinformaticsworkforce

• Mostprevalentinclinicalinformatics,butplentyofotheropportunityinotherareasofinformatics– Bioinformatics– leadingandassisting

computationalanalysisofgenomicsandrelatedtechnologies

– Clinicalandtranslationalresearch– usinginformaticstoaidbiomedicalresearch

– Publichealth– usinginformationtoprotectthepublicandpromotehealth

– Consumerhealth– helpingthegeneralpopulationmaintainandimprovehealth

– Imaginginformatics– usingimagesforbiomedicalresearch,clinicalcare,etc.

43

WhyisitcriticaltohaveacompetentHITworkforce(Hersh,2010)?

• SeniorHITleaderspersistentlyliststaffingconcernsamongtheirmostimportant– Chiefinformationofficers(CIOs)state“clinicalsoftwareimplementationandsupport” astheirtopneed(CHIME,2012)

– Keybarrierinmeetingpriorities;topneedsincludeclinicalapplicationsupport,network/architecturesupport,andclinicalinformaticsprofessionals(HIMSS,2014)

• HIThasa“talentshortage”(HealthITJobs.com,2015)• Growingroleofphysicians(Shaffer,2016;SSiSearch,2015),includingnewclinicalinformaticssubspecialty(Detmer,2014);nurses(Manos,2012;HIMSS,2014);andothers,includingnon-clinicians(Fenton,2012)

44

23

Needsforworkforce(Fenton,2012)

• SurveyofTexasHITemployersfoundneedfor“diverseknowledgeandskillsrangingfrombasictoadvanced,whilecoveringinformationtechnology,privacyandsecurity,clinicalpractice,needsassessment,contractnegotiation,andmanyotherareas.”

• Consistentthemes– employeesmust– Beabletolearnonthejob– Possesstheabilitytothinkcriticallyandproblemsolve– Havetechnicalskills,yetalsoknowledgeandunderstandingofhealthcareoperations

• EmployersuncertainaboutcareerpathwaysandadvancementinHIT

45

WhatweknowabouttheHITworkforce(Hersh,2010)

• Limitedbylackofpresenceinfederallaborstatistics(StandardOccupationalClassification),whichmaybechanging(AMIA,2016)

• Traditionalgroupingsofprofessionalsinhealthcare– Informationtechnology(IT)– usuallywithcomputerscienceorinformationsystemsbackground

– Healthinformationmanagement(HIM)– historicalfocusonmedicalrecords

– Clinicalinformatics(CI)– oftenfromhealthcarebackgrounds,performinganalysis,training,etc.

– Others– librarians,managers,etc.• Whatdothedatashow?

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24

HIMSS2014WorkforceSurvey• About79%reportedplanstohireinthefollowingyearin2013survey,

with84%reportingthattheydidactually• About82%reportedplanningtohirein2014,withabouthalfplanningto

hire1-5FTEandtheremainderplanningtohiremore(10%plantohiremorethan20FTE!)

• Tophiringneedsforproviderorganizations– ClinicalApplicationSupport- 64%– HelpDesk- 57%– ITManagement- 45%– ProjectManagement- 35%– ITSecurity- 34%

• Tophiringneedsforvendorsandconsultants– Sales/MarketingTeam- 78%– FieldSupportStaff- 75%– SupportStaff- 73%– ExecutiveTeam- 60%

47

DemandstrongforexperiencedHITstaff(CHIME,2012)

• Skillsmostoftenindemand– Clinicalsoftwareimplementationandsupportstaff(e.g.,EHR,CPOE)– 74%

– Infrastructurestaff– 47%– Businesssoftwareimplementationandsupportstaff– 45%

• 71%saidITstaffshortagescouldjeopardizeanenterpriseITproject,while58%saidtheywoulddefinitelyorpossiblyaffectmeetingmeaningfulusecriteriaforincentivefunding

• 85%alsoexpressedconcernsaboutbeingabletoretaincurrentstaff

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25

HIM• HIMisafieldintransition,withleadershippromotingadvancedskills,degrees,andwork(Calhoun,2012;Kloss,2012)– Careermap– http://hicareers.com– Callto“adaptordisappear”(Butler,2014)

• HIMisonlyinformatics-relatedareaseeninUSBureauofLaborStatistics(BLS)data– Occupationalemploymentprojections2014-2024(BLS,2015)

• MedicalRecordsandHealthInformationTechnicians(RHITandCCS)– about188,600employedin2014,increasingby29,000by2024(15%growth)

– RHIAs andotherrolesnotcountedinthesenumbers

49

Clinicalinformatics• Individualswhobringskillsatintersectionofhealthcare

andIT(Hersh,2010)• BecominghardertodistinguishfromIT(HealthITJobs.com,

2015)– “TheprimaryskillgapinhealthcareIT-- specificallyClinicalSystems(EMR/EHR)-- isthatmostleadersarelookingforemployeeswithbothhands-onclinicalexperienceandtechnicalexpertise.Historically,thesehavebeentwoveryseparateskillsets.”

• Estimatesofneed– OnephysicianandnurseineachUShospital(~10,000)(Safran,

2005)– Probablymuchlarger– manyUShospitalsnowhaveclinical

informaticsdepartments,oftenreportingtoChiefMedicalInformaticsOfficer(CMIO)(Shaffer,2016)

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26

Certificationofphysiciansandothers

• PhysiciansubspecialtycertificationapprovedbyAmericanBoardofMedicalSpecialtiesin2011(Detmer,2014),basedoncorecurriculum(Gardner,2009)andtrainingrequirements(Safran,2009)– Subspecialtyofallmedicalspecialties– “Grandfathering” oftrainingrequirementsinitially,tobefollowedby

formalfellowshipsafter2022(originally2017;extendedin2016)– CertificationfirstofferedinOctober,2013– nowover1300passed– http://www.amia.org/clinical-informatics-medical-subspecialty– http://www.theabpm.org/abpm_clinical_informatics.pdf

• Neededordesiredforothers?– AMIAHealthInformaticsCertification(AHIC)TaskForcehasdeveloped

plansforcertificationofotherhealthprofessionalsininformatics(Gadd,2016;Gadd,2016)

• https://www.amia.org/advanced-health-informatics-certification

51

Pause

• Turntoaneighboranddescribeaninstanceinyourworkwhereinformaticsexpertisecontributedtoimprovingsomeaspectofyourorganization’sactivities

• Iwillaskforafewtovolunteertheanswers

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27

Resourcesforfield

• Organizations• Information• Education

53

Otherprofessionalorganizations• AmericanMedicalInformaticsAssociation(AMIA)– www.amia.org

• HealthcareInformationandManagementSystemsSociety(HIMSS)–www.himss.org

• AmericanHealthInformationManagementAssociation(AHIMA)–www.ahima.org

• AssociationofMedicalDirectorsofInformationSystems(AMDIS)–www.amdis.org

• AllianceforNursingInformatics(ANI)– www.allianceni.org• PublicHealthInformaticsInstitute(PHII)– www.phii.org• InternationalSocietyforComputationalBiology(ISCB)– www.iscb.org• SocietyforImagingInformaticsinMedicine(SIIM)– www.siim.org• AssociationforComputingMachinery(ACM)– www.acm.org• MedicalLibraryAssociation(MLA)– www.mlanet.org

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Importantroleforgovernmentagencies

• NationalLibraryofMedicine(NLM)hasbeenhistoricleaderinresearchandtraining– www.nlm.nih.gov– OtherinstitutesofNationalInstitutesofHealth(NIH)havesupported

informaticsinvariousways• AgencyforHealthcareResearch&Quality(AHRQ)hasfocusedonapplied

clinicalinformatics– www.ahrq.gov

• OfficeoftheNationalCoordinatorforHealthIT(ONC)hasledhealthITandstandardsadoption– www.healthit.gov

• CriticalroleofotherfederalagenciesinDept.ofHealthandHumanServices,e.g.,– CentersforDiseaseControlandPrevention(CDC)– CentersforMedicareandMedicaidServices(CMS)– FoodandDrugAdministration(FDA)

55

Medicalandnursingspecialtysocieties(non-exhaustive)

• AmericanMedicalAssociation(AMA)– www.ama-assn.org

• AmericanNursesAssociation(ANA)–www.nursingworld.org

• AssociationofAmericanMedicalColleges(AAMC)–www.aamc.org

• AmericanCollegeofPhysicians(ACP)–www.acponline.org

• AmericanAcademyofFamilyPhysicians(AAFP)–www.aafp.org

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29

Wheredoesonefindmoreinformation?Textbooks

• Shortliffe andCimino (eds.),BiomedicalInformatics:ComputerApplicationsinHealthCareandBiomedicine(4thEdition),Springer,2014

• HoytandYoshihashi (eds.),HealthInformatics:PracticalGuideforHealthcareandInformationTechnologyProfessionals(6th Edition),Lulu.com,2014

• Sengstack andBoicey,MasteringInformatics:AHealthcareHandbookforSuccess,SigmaThetaTauInternational,2015

• Abdelhak etal.,HealthInformation:ManagementofaStrategicResource (5th Edition),Saunders,2015

• LaTour andEichenwald,HealthInformationManagement–Concepts,Principles,andPractice(3rd Edition),AHIMA,2013

• SaylesandTrawick,IntroductiontoComputerSystemsforHealthInformationTechnology (2nd Edition),AHIMA,2014

• WilsonandMcEvoy,HealthITJumpStart- YourBestFirstStepTowardaCareerinHealthIT.Wiley,2012

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Wheredoesonefindmoreinformation(cont.)?Textbooks

• Weaveretal.(eds.),NursingandInformaticsforthe21stCentury,HIMSS,2010• Richesson andAndrews(eds.),ClinicalResearchInformatics,Springer,2012• Kann andLewitter (eds).TranslationalBioinformatics,PLoS,2013• MagnusonandFu(eds.),PublicHealthInformaticsandInformationSystems (2nd Edition),Springer,

2014• BuiandTaira (eds.),MedicalImagingInformatics,Springer,2010• Hersh,InformationRetrieval:AHealthandBiomedicalPerspective (3rd Edition),Springer,2009• BerkowitzandMcCarthy,InnovationwithInformationTechnologiesinHealthcare,Springer,2012• Berner (ed.),InformaticsEducationinHealthcare:LessonsLearned,Springer,2014• Sarkar,(ed.),MethodsinBiomedicalInformatics:APragmaticApproach,AcademicPress,2014• Lesk,IntroductiontoBioinformatics (4th Edition),OxfordUniversityPress,2014• Giannangelo,K,(ed.),HealthcareCodeSets,ClinicalTerminologies,andClassificationSystems,Third

Edition.Chicago,IL,2015• ReddyandAgarwal(eds.),HealthcareDataAnalytics,Chapman&Hall,2015• BensonandGrieve,PrinciplesofHealthInteroperability- SNOMEDCT,HL7andFHIR,ThirdEdition.

Springer,2016• Dixon,B(ed.).HealthInformationExchange- NavigatingandManagingaNetworkofHealth

InformationSystems.Amsterdam,Netherlands,Elsevier,2016• Skochelak etal.(eds.).HealthSystemsScience.Elsevier,2017

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30

Moreinformation(cont.),Journals

• JournalofAMIA (JAMIA,http://jamia.oxfordjournals.org)• JournalofMedicalInternetResearch(JMIR)• AppliedClinicalInformatics(ACI)• InternationalJournalofMedicalInformatics (IJMI)• JournalofBiomedicalInformatics (JBI)• MethodsofInformationinMedicine (MIM)• Bioinformatics• JournalofDigitalImaging (JDI)• BiomedCentral(BMC,www.biomedcentral.com)

– BMCMedicalInformaticsandDecisionMaking– BMCBioinformatics

59

Moreinformation(cont.),Meetings

• AMIA-relatedmeetings– AMIAAnnualSymposium– AMIASummitsonTranslationalSciences– AMIAiHealth– Medinfo (biennial)

• Otherclinicalinformaticsmeetings– HIMSS,nationalmeetingandlocalchapters– AMDISPhysician-ComputerConnection

• Bioinformaticsmeetings– PacificSymposiumonBiocomputing (PSB)– InternationalSocietyforComputationalBiology(ISCB)

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31

Moreinformation(cont.),Websites

• USgovernment– NLM– www.nlm.nih.gov,includingwww.pubmed.gov– HHSONC– www.healthit.gov– AHRQNationalResourceCenterforHealthIT–

http://healthit.ahrq.gov– HRSAHealthITToolbox– partofAHRQNationalResource– USHealthInformationKnowledgebase– http://ushik.ahrq.gov

• Other– HITECHAnswers– www.hitechanswers.net– Clinfowiki – http://clinfowiki.org– ElectronicMedicalInformaticsRepositoryofResources(e-MIR2;

delaCalle,2012)– http://www.gib.fi.upm.es/eMIR2/

61

Moreinformation(cont.),emaillistsandblogs

• Emaillists– HISTalk – http://histalk2.com– HITStrategist–

http://www.modernhealthcare.com/section/HITSarchive/– FromorganizationssuchasAMIA,HIMSS,AMDIS,etc.

• Blogs– (many!)– GeekDoctor(JohnHalamka,MD)–

http://geekdoctor.blogspot.com– HealthcareStandards(KeithBoone)–

http://motorcycleguy.blogspot.com– HealthITBuzz(ONC)– http://www.healthit.gov/buzz-blog/– TheHealthcareBlog– http://thehealthcareblog.com– InformaticsProfessor(Hersh)–

http://informaticsprofessor.blogspot.com

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Moreinformation(cont.),acronyms

• Alwaysasked,sohereisalist– HITECHAnswers–http://www.hitechanswers.net/ehr-adoption-2/key-acronyms/

– AMIA– https://www.amia.org/glossary– Shortliffe glossary,whichincludesacronyms(2014)–http://people.dbmi.columbia.edu/shortliffe/docs/Glossary%20-%204th%20ed.pdf

– Wikipedia–https://en.wikipedia.org/wiki/List_of_abbreviations_used_in_health_informatics

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Educationandtrainingininformatics

• Educationhashistoricallyfocusedonacademicsbuthasbeenexpandingtomeettheneedsandopportunitiesofpractitionersandusers

• Anever-growingnumberofprogramsatassociate,baccalaureate,andgraduatelevels– Alsoshorter,continuingeducationcourses,suchas10x10(“tenby

ten”)– https://dmice.ohsu.edu/hersh//10x10.html• Informaticsprogramscomeinmanyflavors:medical,clinical,

biomedical,health,bio-,nursing,etc.• MajorfunderofprogramsisNLM,whichfundsfellowshipstotrain

futureresearchersatdoctoralandpostdoctorallevels• NewAccreditationCouncilforGraduateMedicalEducation

(ACGME)-accreditedclinicalfellowshipprogramsemerging– ~20accreditedand~10launched

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Academicprograms• ListofUSinformatics

programsonAMIAWebsite– http://www.amia.org/educati

on/programs-and-courses• Internationalcompendiumof

programsatHealthInformaticsWorldwide(HIWW)– www.hiww.org

• NLM-fundedprograms– http://www.nlm.nih.gov/ep/G

rantTrainInstitute.html

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Inventoryofcompetenciesforvariousgroups(Hersh,2010)

• Competenciesdifferbygroup– Informaticians

• Developing,implementing,andevaluatingsystems

• Makingoptimaluseofinformation

• RecentelucidationofcorecompetenciesbyAMIA(Kulikowski,2012)

– Clinicians• Applyinginformaticsindelivery

ofcare• Competenciesformedical

education(Hersh,2014)– Patients

• Healthinformationliteracy

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…

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Clinicalinformaticseducationforclinicians

Startedwithmedicalstudents(Hersh,2014),butinrealityapplicabletoallclinicalstudentsandprofessionals

Partoflargerhealthsystemsscience(Skochelak,2017;Hersh,2017)

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Careerpathwayshavediverseinputsandoutputs(Hersh,2009)

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Healthcareprofessions,e.g.,medicine,nursing,etc.

Naturalandlifesciences,e.g.,biology,genetics,etc.

Computerscience(CS),IT,andundergradinformatics

Healthinformationmanagement(HIM)

Others,e.g.,business,libraryandinfo.science

Jobsin:• Healthcaresystems

• Clinicalleadership• ITleadership

• Biomedicalresearch• Industry• Academia

Biomedicalandhealthinformaticseducation(graduatelevel)

Thereisnosinglecareerpathway,ladder,etc.

Therearemanycareeropportunitiesinmanysettingsforalltracks

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Example:OHSUinformaticshttp://www.ohsu.edu/informatics

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International students from: Argentina, Singapore, Egypt, Israel, Saudi Arabia, Zimbabwe, Thailand, China, and other countries

Track Degree/Certificate PhD MS MBI GradCert

ClinicalInformatics On-campusOn-campus

On-line

On-campus

On-line

On-campus

On-line

Bioinformatics andComputationalBiology

On-campus On-campus

DegreesAwarded1998-2016(653people)Track CI BCB TotalCertificate 406 0 406MBI/MMI 190 8 198MS 72 16 88PhD 18 6 24Total 686 30 716

HowhaveOHSUstudentsandgraduatesdone?

• About25yearsofexperience…• Generalobservation:Whatpeopledowhentheygraduateispartiallydependentonwhattheydidwhentheyentered,e.g.,– Physicians,nurses,publichealth,etc.drawontheirclinical/professionalbackground

– Informationtechnologyprofessionalsdrawontheiruniquebackgroundandexperience

• Graduateshaveobtainedjobsinavarietyofsettings,e.g.,clinical,academic,andindustry

• Someobtainjobsbeforefinishingprogram

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Conclusions

• Theseareexcitingtimesforbiomedicalandhealthinformatics,withmanyopportunitiesinawidevarietyofsettings

• Attentionmustalsobepaidtotheprofessionalpracticeandeducationofinformaticians

• Butthemainfocusofthefieldmustbehowtooptimallyuseinformationandtechnologyproperlytoadvancehumanhealthandimprovedeliveryofhealthcare

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