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

220 September 2010 2

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


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


More recently, it gets better ...

Ongoing fellowships General medicine rediscovers board

certification Advertising for these skills


The explorers

Bill Dito, Art Rapapport, George Brecher, Homer Warner, Phil Hicks, many others

Self taught From basic data management to deeper

analysis


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


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


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.


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


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


“Just in time” knowledge

Calling your friends Local colleagues Google, Wikipedia, etc API listserv


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”)


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


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


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


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


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


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.


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...


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.


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


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”


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


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.


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.


How many faculty?

.. at least 40% time doing informatics (service, research, teaching, etc)

One, one, two, two + six, 5, 14


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


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)


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


General medical informatics programs

Interaction with NLM funded general medical informatics fellowship?

MGH - available, but not best option Some others – not available


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.”


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”


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


Effect on faculty workload

Faculty time

Weeks -->


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.


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


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.


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.


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.


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


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)


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


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


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


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 ......


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


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


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.


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”


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).


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


What are candidates interested in?

“Recently, have seen increased interest from people that want to be directors of core labs.”


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


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”


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


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


Thank you!

I appreciate your attention raller @ usc.edu

I welcome your questions

Documents

Training in Pathology Informatics: Lecture, Project, Rotation, Fellowship and beyond