Keywords
clinical informatics - professional training - education - Accreditation Council on
Graduate Medical Education - Centers for Medicare and Medicaid Services - education
and strategies for HIT
Background and Significance
Background and Significance
The future of medicine must be characterized by the delivery of superior care with
measurable improvements in outcomes and reduced cost. Necessary for this future are
an optimized, usable, and interoperable health information technology (HIT) and clinicians
with expertise in the systematic collection, analysis, and application of data. Board
certified clinical informaticians provide such expertise in leveraging HIT and health
data for patient care and quality improvement.[1]
[2] Clinical Informatics experts possess the requisite skills and competencies to make
systems-level improvements in care delivery using HIT, workflow and data analytics,
knowledge acquisition, clinical decision support, data visualization, and related
informatics tools. However, the sustainability and growth of this new and promising
medical subspecialty—and its effect on care delivery—are threatened by outdated and
inconsistent funding models that fail to support the education and professional growth
of Clinical Informaticians when compared with other clinical specialties.[3] Currently, only approximately 70 fellowship positions are available annually for
Clinical Informatics. Considering the informatics expertise needed for the more than
5,500 hospitals in the United States, it becomes apparent that without an increased
pipeline of trained and educated informaticians, health care systems will continue
to struggle to find the talent needed to implement, maintain, update, and optimize
their clinical information systems and data. Subsequently, a lack of appropriately
trained and educated Clinical Informaticians perpetuates underperformance in the pillars
of value-based care—patient safety, care quality, and cost reduction.
American Medical Informatics Association (AMIA) Community of Clinical Informatics
Program Directors (CIPD) urges Congress and the current Administration to establish
structural and specified funding mechanisms for the training of Clinical Informatics
fellows. The CIPD's primary purpose is to establish and maintain high standards of
excellence in Clinical Informatics training programs. Training programs are defined
as those approved by the Accreditation Council on Graduate Medical Education (ACGME)
that lead to eligibility for subspecialty certification by the American Board of Preventive
Medicine or the American Board of Pathology in Clinical Informatics. The CIPD creates
an environment that encourages the development of ACGME-accredited fellowships in
Clinical Informatics and supports the continued evolution of these programs. The CIPD
also provides a forum for training programs, aspiring training programs, and other
interested parties to collaborate, network, and exchange information and ideas to
support these purposes.
Having recognized a growing need for more Clinical Informatics education, we call
on policymakers and federal funders to create direct support for ACGME-accredited
Clinical Informatics fellowships through competitive, institutional grants funded
through the Centers for Medicare and Medicaid Services (CMS) Innovation Center.
Inadequate Use of Clinical Informatics Has Stymied Health Information Technology Optimization,
Value-Based Care
Inadequate Use of Clinical Informatics Has Stymied Health Information Technology Optimization,
Value-Based Care
The federal government has subsidized the U.S. health care system's modernization
with $37 billion to encourage hospitals and physicians to adopt and use electronic
health records (EHRs) and other HIT. Unfortunately, the entanglement of EHRs and HIT
with clinical workflows, business processes, and regulatory compliance activities
has had the opposite effect of the anticipated benefits of a digital health care system
by harming the patient–doctor relationship,[4] reducing clinician satisfaction,[5]
[6] increasing physician burnout,[7]
[8] increasing costs,[9] and leading to mixed effects on quality and safety of patient care.[10] Moreover, the significant investment in technology failed to be linked to an equally
significant investment in professionals, who can be interlocutors between clinicians
in the front lines of health care delivery and the developers and engineers, who build
the technology. In fact, our national investment in HIT infrastructure has not been
matched by any federal investment for the training and support of physician informaticians,
who are trained to optimize clinical workflows and decision support and deliver data-driven
insights for better patient care, resulting in a disconnect between physicians' needs
and systems built.
The effects of failure to invest in the education of informaticians are not only visible
in our fee-for-service systems, but the national foray into value-based payment models,
which has also shown little results. From bundled payments[11] to medical homes and value-based purchasing,[12]
[13] the savings accrued through risk sharing have been underwhelming, especially when
compared with the predicted savings.
While the mediocre status quo can be attributed to many reasons, a primary culprit
is lack of a sufficiently trained workforce, qualified to make systems-level improvements
in care delivery using informatics. The implementation of EHRs alone is insufficient
as much of the functionalities of commercial EHRs are designed poorly and require
extensive improvements and customization.[14]
A key missing ingredient has been formal Clinical Informatics education and training.[15]
[16] Without experts trained to extract the potential value out of EHRs for patients,
payers, and providers, the government's investment in HIT will continue to generate
only a fraction of the anticipated gains.
Federal Funding Models for Medical Education Must Be Reformed
Federal Funding Models for Medical Education Must Be Reformed
Accreditation by ACGME is considered by United States the gold standard for graduate
medical education because it sets the foundation for a structured fellowship program
with defined goals, objectives, and evaluations resulting in board eligibility. Subsequent
“board certification is important as it[1] allows physicians to demonstrate exceptional expertise in a particular specialty
and/or subspecialty[1] and benefits society by encouraging physicians to seek, maintain, and demonstrate
a higher level of skills, knowledge, and expertise than is required of nonboard certified
physicians.”
CMS in the United States has traditionally subsidized specialty and subspecialty education
programs. However, Clinical Informatics fellowships are not supported by CMS, unlike
residencies and fellowship in most other specialties and subspecialties. In the 5-year
history of the subspecialty, less than 40 individuals have become board-eligible in
Clinical Informatics through completing an ACGME-accredited clinical informatics fellowship.
Rather, the vast majority of board-certified Clinical Informaticians (∼1,700) became
eligible through the practice pathway (i.e., experience), which will end permanently
in 2022.[1] The fellowship pathway will remain as the only way to Clinical Informatics certification
and will be unable to provide sufficient numbers of graduates unless more programs
become available, which remains highly unlikely due to the lack of funding.
Training a Clinical Informatics fellow creates a cost of over $150,000 per year including
the fellow's salary and benefits, as well as the educational costs. Currently, these
costs are carried solely by the training health care system. The first ACGME-accredited
Clinical Informatics fellowship programs were initiated with philanthropic donations
and supported through myriad, nonsustainable financing mechanisms at medical centers.
Unlike most other ACGME fellowships and residencies, Clinical Informatics lacks a
revenue stream directly related to billing for patient services. Additionally, as
most institutions are at or exceed the cap of trainees supported directly by CMS,
most Clinical Informatics programs do not benefit from this federal support. Even
though Clinical Informaticians have an enormous effect on patient care through HIT,
CMS does not consider this direct patient care for reimbursement purposes. While a
few Clinical Informatics programs have grown over the last 5 years, many nascent programs
are unable to initiate training due to a lack of funding and existing programs struggle
to maintain financial support year over year.
Despite these challenges, some forward-thinking organizations have recognized the
value informaticians deliver for patients, payers, governments, and health systems.
These institutions are funding informatics fellowships and employing Clinical Informaticians
because they recognize that HIT, optimized through informatics tools and methods,
is critical for the delivery of safe, economical, and effective clinical care. However,
with more than 5,500 hospitals in the United States and less than 100 training positions
currently offered annually, there is clearly insufficient expertise to meet the demand
for trained and qualified informaticians. Federal support for Clinical Informatics
fellowships will improve the pipeline of informaticians, who are necessary to improve
health care and address long-overdue shortcomings in how we fund medical education.
An Imperative for the Future of Medicine and the Future of U.S. Health Care
An Imperative for the Future of Medicine and the Future of U.S. Health Care
Clinical Informaticians benefit both patients and payers through reduction of errors,
increased safety, reduced costs, more efficient care, and improved care coordination.
In contrast to other physicians, who typically focus on the individual patient, most
clinical informaticians work at a practice or population level, affecting the care
of many patients through their efforts. In addition, many solutions developed by informaticians
can be transferred to or duplicated at other institutions, increasingly the possibility
that informaticians may save lives or reduce costs in institutions that they have
never visited.
We view Clinical Informatics competencies as prerequisite for value-based payment
success and an imperative for the modernization of medicine through health informatics.
Thus, through the CMS Innovation Center, we strongly recommend that CMS provide structural
and sustained funding for Clinical Informatics fellows. To operationalize this recommendation,
we offer below a series of options leading toward funding of ACGME accredited Clinical
Informatics fellowships.
First, dozens of innovative funding models have been tested and analyzed through the
CMS Innovation Center, also known as CMMI.[17] However, these models have not been reviewed holistically to understand how a workforce
trained to collect, analyze, and apply data to patient care can affect safety, quality,
and cost. CMS should task its Innovation Center to offer a multiyear training grant
for ACGME-accredited institutions to propose, measure, and report how Clinical Informatics
fellows would improve the quality and cost of care. Such an approach would highlight
the achievements and benefits derived from the clinical Informatics subspecialty and
would create evidence and would bring the work of Clinical Informatics into visibility.
Second, CMMI should engage in targeted evaluations to identify the benefits created
by participants, who employ trained physicians in Clinical Informatics. These grants
could determine average costs savings per program/fellow to CMS, a portion of which
could be dedicated to expanding institutional limits of ACGME trainees, with the goal
of creating a long-term and sustainable funding model.
While we recommend that CMS provide dedicated funding for Clinical Informatics training
grants, an additional recommended approach would be for CMMI to implement enhanced
application requirements that further promote and optimize the use of informatics
tools and capabilities in select payment models tested by CMMI. Indeed, AMIA has advocated
for this in previous policy statements.[18]
[19] Based on the results of these informatics-enhanced payment models, appropriate steps
by CMS could find sustainable funding mechanisms or implement incentives for institutions
to prioritize training for these specialists.
We have entered an era, where the practice of medicine is no longer limited to medical
devices and drugs to improve patient outcomes. Clinical Informatics and data are an
integral part of the practice of medicine in the 21st century. Practicing medicine
without the help of Clinical Informatics equals practicing outdated or inefficient
medicine. We must demand that EHRs leverage evidence-based informatics tools and methodologies.
However, we cannot expect health care organizations to support an unfunded mandate
of improving the usability and usefulness of HIT systems without trained expert help.
By providing grants for training and supporting efforts to define and document the
value that clinical informaticians bring to modern medical care, we cannot only meet
the above goals but also provide the evidence that will lead to health systems' increasing
willingness to support these activities financially in the future. Only through structural
and sustained funding for Clinical Informatics fellows will the future, we are striving
to achieve, be within reach.
Clinical Relevance Statement
Clinical Relevance Statement
Clinical Informatics is a boarded specialty in which fellows are trained in the systematic
collection, analysis, and application of data. Board certified Clinical Informaticians
provide such expertise in leveraging HIT and health data for patient care and quality
improvement. Clinical Informatics experts possess the requisite skills and competencies
to make systems-level improvements in care delivery using HIT, workflow and data analytics,
knowledge acquisition, clinical decision support, data visualization, and related
informatics tools. The sustainability and growth of this new and promising medical
subspecialty is threatened by outdated and inconsistent funding models that fail to
support the education and professional growth of Clinical Informaticians.
Multiple Choice Questions
Multiple Choice Questions
-
To be board eligible in 2023, Clinical Informaticists must complete a
Correct Answer: The correct answer is option a. In 2023, the only pathway to board eligibility in
Clinical Informatics is an ACGME-accredited Clinical Informatics Fellowship. Answers
b and c might have provided alternative pathways prior to 2023. Option d has not been
such a pathway.
-
All ACGME-accredited Clinical Informatics Fellowships are funded by
Correct Answer: The correct answer is option d. The challenge facing Clinical Informatics fellowship
is the funding mechanisms are multiple, inconsistent, and vary literally by site.
Some of the mechanisms are not sustainable. The question asks about “all” fellowships
so while options b and c are true at some sites they are not true for all. Option
a could be true but each site receives limited funding from CMS and not every site
uses this limited fund to support Clinical Informatics Fellowships. Again, the question
asks “all.”
