The challenge of developing a clinical informatics fellowship program

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon
 - Christopher Longhurst
Christopher Longhurst, MD, chief medical information officer for Stanford Children’s Health

Clinicians looking to get certified in the clinical informatics subspecialty flocked by the hundreds to take the inaugural American Board of Preventive Medicine board certification exam last fall. They’ll have the same opportunity this fall but should remember that this pathway to certification is only available until 2017.

Beginning in 2018 the American Board of Medical Specialties will require physicians to complete a clinical informatics fellowship program accredited by the Accreditation Council for Graduate Medical Education (ACGME) in order to be eligible for certification in the subspecialty.

This means that there is going to be a need over the next five years—and beyond—for the development of ACGME-accredited fellowship programs to ensure there are enough physicians graduating into the field of clinical informatics.

Seven of the physicians who sat for the clinical informatics board last fall came from Stanford Medicine, according to Christopher Longhurst, MD, CMIO for Stanford Children’s Health and clinical associate professor of pediatrics and of medicine at Stanford School of Medicine. It was also about that time, he said, that Stanford Medicine began seriously thinking about launching a fellowship program.

Such a program at Stanford makes sense on a number of levels, said Longhurst. For example, the institution has a long history of experience with biomedical informatics. “And we had lots of great practice ideas and even funding sources from local industry to launch the program and innovate in this field,” he said. “The fellowship offers an opportunity to get a steady stream of people that we can train in the subspecialty, but who can also help launch innovative projects at the medical center.”

According to Longhurst, a lot of legwork was done last year preparing to launch the fellowship, which was announced last fall (with Longhurst becoming fellowship director). Twelve candidates were interviewed for two fellowship positions, and the first two fellows were accepted into the program starting July 1 of this year. In addition, Stanford submitted the application for ACGME accreditation this past spring and received word on July 15 that it was the first program in the country to get accredited.

ACGME accreditation is “pretty standardized” said Longhurst, “which is one of the benefits of this fellowship structure. Previously there were a lot of nonstandard, one-off types of fellowships in informatics across the U.S.” According to Longhurst, these programs could vary in length from one to three years, and might or might not offer fellows experience in a clinical setting.

“So, part of the benefit of ACGME is to bring a level of standardization to these fellowships so that you can compare apples to apples,” Longhurst said. “It brings a level of rigor that physicians are used to in graduate medical education. What it’s saying is that you don’t become an applied clinical informaticist by getting a master’s degree, you do it by working in a healthcare setting and understanding the realities of health information technology in medical care.”

One of the unique aspects of the clinical informatics subspecialty is that it doesn’t have a primary specialty—fellows can come from any of a variety of specialties. “And I see that as presenting a lot of opportunities,” Longhurst said.

The first two fellows for 2014-16 are Lance Downing, MD, an internal medicine specialist, and pediatrician Veena Goel, MD. Downing is helping Christopher Sharp, MD, CMIO and fellowship site director for Stanford Health Care and clinical associate professor of medicine at the Stanford School of Medicine, and others to develop a program to identify early signs of severe sepsis, while Goel is helping Paul Sharek, MD, medical director of quality management and associate professor of pediatrics at the Stanford School of Medicine, to develop new tools and processes to mitigate bedside alarm fatigue.

The department of information services at Stanford Children’s Health will be the primary training site for the fellows, with rotations offered at Stanford Health Care, Sutter Health, Kaiser Permanente, Veterans Affairs Palo Alto Health Care System and HP Labs.

“For the coming year we have commitments from the departments of radiology and pathology to fund fellows if we get strong applicants from their specialties,” said Longhurst. “So we’ve got an umbrella program that can provide a good foundational experience for any candidate.”

Longhurst said that his understanding is that at least a dozen programs—and maybe as many as 20—will be going for ACGME accreditation this year. Still, there have been questions raised whether there will be enough accredited programs in place by 2018.

“If we only end up with fellowship programs at major medical academic centers then it is clear we won’t have enough training programs to graduate the number of physicians we need to be involved in the field,” said Longhurst. “So we absolutely need to provide models for other hospitals and healthcare providers to launch these fellowships.”

Longhurst referred to the distance-learning program in medical informatics at Oregon Health & Science University (OHSU), led by William Hersh, MD, as a tool that can be used to facilitate these fellowship programs. “We’re actually offering didactic support through (Hersh’s) distance learning program,” Longhurst said. “Distance learning and online collaboration makes sense for an informatics fellowship and it’s also good for our fellows to network across the nation.”

Longhurst added that the OHSU program has done a good job of mapping five of its core courses to the core competencies required by the fellowship. “So that model makes it possible for community hospitals and integrated delivery networks like Kaiser to launch fellowship programs where they are getting their academics through a OHSU or Northwestern distance program while essentially doing an experiential rotation through their health system,” he said. “So I think it’s feasible that fellowships can grow beyond academic medical centers, but there’s still a question whether they will ramp quickly enough in the next five years.”

And that leads to the question of what exactly board certification will mean for the specialty going forward, said Longhurst. “Are we going to reach a point in which you wouldn’t hire a CMIO who wasn’t board certified?”

The experience of other specialties could serve as an example of what could happen with clinical informatics, Longhurst observed. For example, when emergency medicine became a board eligible subspecialty in the 1980s a number of internists and other physicians who had practiced emergency medicine for years grandfathered into the subspecialty.

“But at the point at which people could no longer grandfather in, that didn’t mean every room emergency room doctor was board certified,” he pointed out. “It took another five or 10 years for the culture to change so that people wouldn’t consider hiring someone who wasn’t board certified in emergency medicine.”

That culture change began in academic medical centers and it eventually became the standard of care to have board-certified emergency medicine physicians in the emergency rooms of other institutions as well, Longhurst said. “I do expect that we will see an evolution over the next 10 years where starting in academic medical centers people will not hire CMIOs who aren’t board certified, and eventually that will become the standard of care that will reach community hospitals as well.”