What does the future hold for the clinical informatics subspecialty

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In 2010 the American Board of Preventive Medicine received formal approval from the American Board of Medical Specialties (ABMS) to move forward with a clinical informatics subspecialty certification.

The idea was that for the first five years subspecialty certification will be largely based on the examination of physicians who were board certified in any ABMS specialty, and have also received training in clinical informatics. After this five-year “grandfather” period, board eligibility will require completion of an Accreditation Council on Graduate Medical Education-accredited fellowship in clinical informatics.

Almost 500 physicians, representing a range of medical specialties, sat for the exam last October, with almost 90 percent of those taking the exam receiving certification.

Despite the apparently successful launch of this new subspecialty, Don Detmer, MD, professor emeritus and professor of medical education at the University of Virginia, and Edward Shortliffe, MD, PhD, professor, department of biomedical informatics, College of Health Solutions, Arizona State University, have concerns about how everything will roll out over the next five years and beyond—concerns they lay out in the May 28 issue of the Journal of the American Medical Association.

First of all, both Detmer and Shortliffe believe that too many people in the broader medical community are simply unaware of what’s happening with clinical informatics.

“We both travel in non-informatics circles as senior physicians in our field and I was kind of stunned that even as recently last fall—with so many people already sitting for the exam—how many of my colleagues had no idea that this subspecialty had been approved and was being offered,” said Shortliffe. “And there are questions regarding how residency review committees will handle the logistics of accreditation for the individual fellowships that are being formed. It seemed like it was a good time to get something into a clinical journal about what’s going on.”

One of the big uncertainties going forward, said Shortliffe and Detmer, has to do with the fellowship program accreditation process. What makes the situation with clinical informatics challenging and somewhat unusual, said Shortliffe, is that “this is the first time a subspecialty has been approved in which there is no restraint on what the primary specialty is.”

For example, if you plan on becoming a pediatric cardiologist you first must be a pediatrician, he explained. “But here’s a subspecialty where the ABMS became persuaded during the approval process that it really didn’t matter [what the primary specialty was].”

And that seems logical considering how multidisciplinary the field is, Shortliffe said, but it also complicates how institutions are going to go about planning for the accreditation process.

“How will review of informatics fellowships be carried out by nine different Residency Review Committees?” asked Detmer and Shortliffe in their JAMA article. “Will there be uniformity in expectations across the specialties or will fellowships evolve to take on an emphasis related to the specialty group with which they are partnering?”

This last question is particularly important considering that the “central thing about clinical informatics is that it needs to be integrated,” said Detmer. “And if it’s unable to pull things together and be the glue to help us work collaboratively to improve technologies like EHRs, it’s not going to be as helpful as it promises to be.”

Another uncertainty has to do with fellowship funding. Traditionally, Shortliffe pointed out, that funding comes from training grants, or more commonly from government funding. “But we’re not sanguine about the probability of an infusion of funding going to these institutions for clinical informatics fellows,” he added.

More likely, Shortliffe and Detmer said, clinical informatics will be competing with already established fellowship programs for funded slots.

“A major factor here is that almost all major hospitals have invested a lot of money to build electronic record systems,” Detmer said. “Having more people who can make them interact and make them more interoperable and functional will become even more important because these investments demand that kind of capability.”

“From a political perspective it would be nice if [institutions] simply came up with new money for these fellows rather than deciding they are going to have one fewer nephrology fellowship next year,” said Shortliffe. “That’s why we refer to the possibility that there will be competition for fellowship slots, money for fellowship funding, or potentially new money because hospitals are realizing—as [Detmer] is describing—that this is an incremental issue and they want to have valid people addressing it.”

Detmer and Shortliffe also wonder whether once the five-year grandfather period is over and the completion of an informatics fellowship becomes necessary for certification there will be a sufficient number of fellowship positions available to generate a substantial number of eligible subspecialists who can take the annual board examinations and satisfy what is expected to be an increasing need for physicians for an expertise in clinical informatics.

“There is a pent-up demand for this type of certification for those already working in the field,” Shortliffe said. “That’s why for the first few years we’ll see large numbers taking the test. That certainly happened last year and we’ll probably see a similar number this year.”

While there won’t be 500 people ready to take the exam five years from now, “we certainly don’t want it to be just 10,” Shortliffe said.

While Detmer said that there is an “intrinsic” interest in the field of clinical informatics and that its importance will attract and drive people into the field, Shortliffe said he is “less worried about whether there will be an interest among physicians being trained in the field than I am whether we can get a large number of high-quality and accredited fellowships in place within five years.”

Shortliffe suggested that the logistical issues involved in funding clinical informatics fellowships means that it will take some time to build up a cadre of these fellowships, “even though it’s obviously a good idea.”

Could we end up with a shortage of qualified clinical informaticians?

“Suppose the numbers start dropping dramatically in 2018,” Shortliffe said. “If there is a mismatch between the number of new people being produced and the demand—which I think there will be—there will be a period in which people are going to get jobs for which they aren’t fully trained. The difference between those people and those who have gone through the fellowship process will become clear and there will be an increasing demand for increased funding of fellowships. That process will happen eventually.”

What does all of this of this mean for the position of CMIO? “I wouldn’t be surprised if there comes a time when you couldn’t become a CMIO if you’re not board certified,” said Shortliffe.

Detmer agreed, adding that while good health IT technicians are always going to be needed, “you also have to have people make these things interface with the actual clinical work so that it actually works for doctors, nurses and the whole healthcare team, and patients and payers, and those are executive function levels.”