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ii Clinical Informatics Board Review Pass the Exam the First Time, Third Edition By Corinn Pope, PMP Rocky Reston, MD, PhD
iii Copyright 2017 by InformaticsPro, Inc. All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2015 Second Printing, 2016 Third Printing, 2017 ISBN 978-0-9863155-4-1 InformaticsPro San Diego, CA www.informaticspro.com
iv 1. Exam Details... 1 1.1 Topics Covered... 1 1.2 Requirements for Certification... 2 1.2.1 Licensure... 3 1.2.2 One of the Following Pathways to Certification... 3 1.3 Exam Day... 5 1.3.1 The Exam Format... 5 1.3.2 Registering for the Exam... 5 1.3.3 The Exam Location... 6 1.4 Chapter One Key Points... 7 2 Clinical Informatics Overview... 8 2.1 What is a Clinical Informatician?... 8 2.2 Informatics History... 9 2.2.1 A History of the Clinical Informatics Subspecialty... 9 2.3 Domains of Informatics... 10 2.3.1 Translational bioinformatics... 10 2.3.2 Imaging informatics... 11 2.3.3 Public health informatics... 11 2.3.4 Clinical informatics... 11 2.4 Informatics as a Career... 11 2.4.1 Interest Groups... 12 2.4.2 Professional Organizations... 13 2.4.3 Professional Certifications... 13 2.5 Current and Future Challenges for Informatics... 13 2.5.1 Interoperability... 13 2.5.2 Usability... 13 2.5.3 Patient engagement... 14 2.5.4 Personalized medicine... 14 2.5.5 Ubiquitous care... 14 2.6 Key Concepts, Models, and Theories in Informatics... 15 2.7 Clinical Informatics Literature... 15 2.7.1 What is Fit for Peer Review?... 16 2.7.2 Critically Analyzing Literature... 17 2.8 International Clinical Informatics Practices... 17 2.9 Ethics in Clinical Informatics... 17 2.9.1 Professional Ethical Conduct... 17 2.9.2 Conflict of Interest... 18 2.9.3 Hippocratic Oath... 18 2.9.4 FTC Fair Information Practice... 18 2.9.5 Human Rights... 19 2.9.6 Ethical Concepts... 19 2.9.7 Ethical Theories... 20 2.9.8 Ethical Decision Making... 21 2.9.9 Current Topics in Bioethics... 22 2.10 Legal and Regulatory Issues... 24 2.10.1 HIPAA... 24 2.10.2 PPACA... 25 2.10.3 HITECH... 25 2.10.4 Joint Commission Standards... 25 2.11 Chapter Two Key Points... 26 2.12 Review Questions... 27 2.13 Answers... 29 2.14 Recommended Reading... 31 3 The Health System... 32 3.1 Determinants of Individual and Population Health... 32 3.2 Domains of the Health System... 32 3.2.1 The Healthcare Delivery System... 32 3.2.2 Healthcare Organizational Structure... 35
v 3.2.3 Accreditation... 36 3.2.4 Licensing & Credentialing... 36 3.2.5 Continuum of Care... 36 3.2.6 Patient Centered Medical Home... 37 3.2.7 Accountable Care Organizations... 38 3.2.8 Public Health... 39 3.2.9 Clinical Research... 40 3.2.10 Health Education for Professionals... 40 3.2.11 Personal Health... 41 3.2.12 Personal Health Information... 41 3.2.13 Personal Health Maintenance... 41 3.2.14 Occupational Health... 41 3.3 Data, Information, and Knowledge Flows... 42 3.3.1 Data and Information Flow... 42 3.4 Policy and Regulatory Framework... 44 3.5 HITECH... 44 3.5.1 Meaningful Use as a Part of HITECH... 44 3.5.2 Meaningful Use Stages... 45 3.5.3 Certified EHR Technology... 45 3.5.4 Registering and Attesting to Meaningful Use... 46 3.5.5 Hardship Extensions... 48 3.5.6 Meaningful Use in 2017... 48 3.6 Physician Quality Reporting System (PQRS)... 48 3.7 Medicare Access and CHIP Reauthorization Act (MACRA)... 49 3.7.1 Merit-Based Incentive Payment System (MIPS)... 49 3.7.2 MIPS Vs. Previous Requirements... 50 3.8 Patient Protection and Affordable Care Act (PPACA)... 52 3.8.1 The Sunshine Act... 52 3.9 Health Insurance Portability and Accountability Act (HIPAA)... 52 3.9.1 HIPAA Privacy Rule & Security Rule... 53 3.9.2 PHI and HIPAA... 53 3.9.3 Noncompliance... 53 3.9.4 Covered Entities Under HIPAA... 54 3.9.5 Privacy Rule Principles Applicable to Health IT... 54 3.9.6 Access to PHI Under the Privacy Rule... 56 3.9.7 The Privacy Rule and Personal Health Records... 57 3.9.8 Additional HIPAA Considerations... 57 3.9.9 HIPAA Breach Notification Rule... 58 3.10 Food and Drug Administration Safety and Innovation Act (FDASIA)... 58 3.11 Health Economics and Financing... 59 3.11.1 Organizational Finance... 59 3.11.2 Financing and Payments in the Health Care System... 61 3.12 Economics... 63 3.12.1 Performing Economic Evaluations... 65 3.12.2 Cost Effectiveness & Cost Benefit Analysis... 65 3.12.3 Markets Within Health Care... 66 3.12.4 Healthcare Spending... 67 3.13 Forces Shaping the Healthcare Delivery System... 67 3.14 Healthcare Quality... 69 3.14.1 Measures of Quality... 70 3.14.2 Performance Management... 71 3.14.3 Utilization Management... 72 3.14.4 Risk Management... 72 3.15 Chapter Three Key Points... 74 3.16 Review Questions... 75 3.17 Answers... 79 3.18 Suggested Reading... 83 4 Clinical Decision Making and Care Process Improvement... 84 4.1 The Nature and Cognitive Aspects of Human Decision Making... 84
vi 4.1.1 Decision Making and Decision Science... 85 4.2 Medical Decision Making... 86 4.2.1 Stage One: Initial Judgments and Pretest Probabilities... 87 4.2.2 Stage One: Determining Objective Probabilities... 88 4.2.3 Stage Two: Analyzing Test Characteristics... 89 4.2.4 Stage Three: Finding the Post-Test Probability... 96 4.2.5 Utility and Preference Assessment... 110 4.2.6 Making the Decision... 112 4.2.7 Cost Effectiveness Analysis... 113 4.3 Application of Clinical Decision Support... 116 4.3.1 Knowledge-Based vs. Non-Knowledge Based CDSS... 116 4.3.2 The Five Rights Model of CDS... 116 4.3.3 Features of CDSS... 117 4.3.4 Benefits and Drawbacks... 117 4.3.5 Types of Decision Support... 118 4.3.6 Users of Decision Support... 119 4.4 Implementing, Evaluating, and Maintaining Clinical Decision Support... 119 4.4.1 Implementation... 119 4.4.2 Evaluation... 120 4.4.3 Maintenance... 121 4.5 Transforming Knowledge into CDS Tools... 121 4.5.1 Knowledge Generation... 122 4.5.2 Knowledge Acquisition... 123 4.5.3 Knowledge Modeling... 123 4.5.4 Knowledge Representation... 124 4.5.5 Knowledge Management and Maintenance... 125 4.6 Legal, Ethical and Regulatory Issues... 126 4.6.1 Ethical Questions in CDS... 126 4.6.2 Legal and Regulatory Issues... 127 4.6.3 FDA Regulation of CDS... 127 4.6.4 CDS In Meaningful Use... 127 4.6.5 CDSS Quality... 127 4.6.6 CDSS Safety... 128 4.7 Supporting Decisions for Population of Patients... 129 4.8 Chapter Four Key Points... 130 4.9 Review Questions... 131 4.10 Answers... 141 4.11 Suggested Reading... 150 5 Evidence Based Patient Care... 151 5.1 Evidence-Based Medicine Sources... 151 5.2 Evidence Grading... 152 5.2.1 AHRQ USPSTF Grading System... 152 5.2.2 AHRQ USPSTF Certainty Levels... 153 5.2.3 Additional Grading Guidelines and Frameworks... 154 5.3 Clinical Guidelines... 154 5.3.1 Developing Guidelines... 155 5.3.2 Developing Guidelines... 156 5.3.3 Sources of Clinical Guidelines... 157 5.3.4 Grading Evidence and Clinical Guidelines... 158 5.4 Implementation of Guidelines as Clinical Algorithms... 158 5.4.1 Implementing and Evaluating Guidelines... 159 5.5 Information Retrieval... 159 5.5.1 Information Retrieval Terminology... 160 5.5.2 Indexing... 160 5.5.3 Term Frequency-Inverse Document Frequency... 161 5.5.4 Retrieving Information... 161 5.5.5 Mathematical & Property Dimensions of Information Retrieval Models... 162 5.5.6 Information Retrieval Performance... 162 5.5.7 Search Skills... 163
vii 5.5.8 Foreground Vs. Background Questions... 163 5.5.9 Levels of Evidence Pyramid... 164 5.5.10 Meta-Analyses... 164 5.5.11 Critical Analysis of Biomedical Literature... 165 5.6 Chapter Five Key Points... 167 5.7 Review Questions... 168 5.8 Answers... 171 5.9 Suggested Reading... 174 6 Workflow Analysis, Process Redesign, and Quality Improvement... 175 6.1 Methods of Workflow Analysis... 175 6.1.1 Documenting Current Workflows... 175 6.1.2 Developing Flowcharts... 177 6.1.3 Workflow Analysis... 178 6.2 Principles of Workflow Re-engineering... 179 6.2.1 Workflow Re-Engineering... 179 6.2.2 The Re-Engineering Process... 180 6.3 Quality Improvement Principles and Practices... 181 6.3.1 Implementing Quality... 182 6.3.2 Quality Assurance and Quality Control... 182 6.3.3 What Organizations Influence Quality?... 182 6.3.4 Quality Improvement Methodologies... 183 6.3.5 The Seven Basic Tools of Quality... 185 6.4 Chapter Six Key Points... 191 6.5 Review Questions... 192 6.6 Answers... 195 6.8 Suggested Reading... 197 7 IT Systems Programming... 198 7.1 Computer Systems... 199 7.2 Programming... 199 7.3 Data and Control Structures in Programming... 202 7.4 Software Development Lifecycle (SDLC)... 211 7.5 Software Quality... 214 7.6 Information Systems Design and Analysis... 215 7.7 Chapter Seven Key Points... 218 7.8 Review Questions... 219 7.9 Answers... 221 7.10 Recommended Reading... 223 8 IT Systems Architecture, Security, and Networking... 224 8.1 Systems Architecture... 224 8.2 System Integration... 225 8.3 Data Warehouse... 228 8.4 Data Mart... 228 8.5 Network Architecture... 229 8.6 Data and Database Architecture... 230 8.6.2 Software Engineering Architectures... 230 8.7 Networks... 233 8.7.1 Network Topology... 233 8.8 Telecommunications... 236 8.9 Security... 238 8.9.1 The HIPAA Security Rule and Other Government Regulations... 238 8.9.2 Firewalls... 242 8.9.3 Virtual Private Networks... 242 8.9.4 Encryption... 243 8.9.5 Security Best Practices... 245 8.9.6 How Hackers Can Access Your Information... 245 8.10 Chapter Eight Key Points... 247 8.11 Review Questions... 248
viii 8.12 Answers... 251 8.13 Recommended Reading... 255 9 IT Systems Data & Databases... 256 9.1 Data Integrity... 256 9.2 Mapping... 257 9.3 Types of Databases... 258 9.4 Data Manipulation & SQL... 261 9.4.2 JOIN Statements... 266 9.5 Data Representation and Types... 269 9.6 Data Warehousing... 270 9.7 Data Mining and Knowledge Discovery... 271 9.8 Technical Approaches that Enable Data Sharing... 275 9.8.1 Non-Technical Approaches... 275 9.8.2 Technical Approaches... 276 9.9 Patient Identifiers & Data Anonymization... 279 9.10 Chapter Nine Key Points... 284 9.11 Review Questions... 285 9.12 Answers... 289 9.14 Suggested Reading... 293 10 Human Factors Engineering... 294 10.1 Human Factors... 294 10.2 Human Factors Engineering... 295 10.2.1 Human Limitations, and Methods to Mitigate Them... 296 10.3 Human-Computer Interaction... 297 10.3.1 Predictive Models... 297 10.3.2 Descriptive Models... 298 10.3.3 HCI Theories & Approaches... 298 10.3.4 Activity Theory... 298 10.3.5 Human-Centered Design... 299 10.3.6 Mental Models... 299 10.3.7 Information Processing Theory... 300 10.3.8 GOMS... 300 10.3.9 Keystroke Level Modeling... 300 10.4 HCI Evaluation... 301 10.4.1 Usability Testing... 301 10.5 Interface Design Guidelines and Principles... 302 10.5.1 Nielsen s Heuristics... 302 10.5.2 Object-Action Interface... 302 10.5.3 Human-Interface Guidelines... 303 10.5.4 Responsive Web Design... 303 10.5.5 AMIA Recommendations for Improving EHR Usability... 303 10.6 Usability Engineering... 303 10.6.1 Usability & Usability Engineering Standards... 304 10.7 Chapter Ten Key Points... 305 10.8 Review Questions... 306 10.9 Answers... 308 10.11 Suggested Reading... 310 11 Health Information Systems and Applications... 311 11.1 Electronic Health Records/Electronic Medical Records... 311 11.2 CDS/CDSS... 312 11.3 Pharmacy Information Systems... 313 11.4 CPOE... 314 11.5 Radiology Information Systems/PACS... 315 11.6 Laboratory Information System... 315 11.7 Inventory & Supply Chain Management... 318 11.8 Medication Administration Systems... 318 11.9 Personal Health Record... 319
ix 11.10 mhealth... 319 11.11 Other Software... 322 11.12 Types of Functions Offered by Health Information Systems... 322 11.13 Types of Settings Where Systems are Used... 323 11.13.1 Clinical Settings... 323 11.13.2 Non-clinical Settings... 323 11.14 EHR Systems as a Foundational Tool... 323 11.14.1 SAFER EHR Interfaces... 325 11.15 Telemedicine... 327 11.16 Chapter Eleven Key Points... 328 11.17 Review Questions... 329 11.18 Answers... 331 12 Clinical Data Standards... 333 12.1 Standards Development History and Current Process... 333 12.1.1 Timeline of Standards Development History... 333 12.1.2 Standards Development Current Process... 334 12.2 Data Standards and Data Sharing... 335 12.2.1 HL7... 335 12.3 Transaction Standards... 341 12.3.1 HIPAA Transaction Standards... 341 12.3.2 Electronic Funds Transfer... 342 12.4 Messaging Standards... 342 12.4.1 Digital Imaging and Communications in Medicine (DICOM)... 342 12.4.2 NCPDP SCRIPT... 343 12.4.3 CEN ISO/IEEE 11073... 343 12.5 Nomenclature, Vocabulary, and Terminology... 343 12.5.1 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)... 344 12.5.2 Logical Observation Identifiers Names and Codes (LOINC)... 345 12.5.3 International Classification of Diseases (ICD) Clinical Modifications (CM)... 345 12.5.4 RxNorm... 346 12.6 Ontology and Taxonomy... 347 12.6.1 Taxonomy... 347 12.6.2 Ontology... 348 12.6.3 Meta-thesaurus... 348 12.7 Interoperability Standards... 349 12.7.1 Levels of Interoperability... 349 12.7.2 FHIR Fast Healthcare Interoperability Resources... 350 12.8 Other standards... 350 12.9 Chapter Twelve Key Points... 352 12.10 Review Questions... 353 12.11 Answers... 358 12.12 Suggested Reading... 362 13 Information System Lifecycle... 363 13.1 Governance... 363 13.1.1 Clinical IT Governance... 365 13.1.2 Rules and Agreements... 365 13.2 The Clinical Information System Lifecycle... 366 13.2.1 Clinical Information Needs Analysis... 366 13.2.2 The Requirements Specification Document... 368 13.3 Risk Management... 369 13.3.1 Planning Risk Management... 369 13.3.2 Risk Identification... 369 13.3.3 Qualitative Risk Analysis... 370 13.3.4 Quantitative Risk Analysis... 371 13.3.5 Risk Response... 371 13.3.6 Controlling Risk... 372 13.3.7 True Cost of Ownership... 372 13.4 System Selection... 373
x 13.4.1 Evaluating The Requests for Proposals... 374 13.4.2 Contracts... 375 13.5 Clinical Information System Implementation... 376 13.5.1 Elements of a System Implementation Plan... 377 13.5.2 User Training... 378 13.5.3 Obtaining Clinician Feedback... 378 13.6 Information System Testing Before, During, and After Implementation... 379 13.6.1 System Validation... 379 13.6.2 Testing Basics... 379 13.6.3 Testing Methods... 380 13.6.4 Testing Levels... 380 13.6.5 Testing Types... 381 13.7 Clinical Information System Maintenance... 381 13.7.1 Data Loss Prevention & Recovery... 381 13.7.2 Disaster Response... 381 13.7.3 Downtime... 383 13.7.4 Backups... 384 13.7.5 Transitioning and Decommissioning... 385 13.8 Clinical System Evaluation... 385 13.8.1 The Evaluation Plan... 385 13.8.2 Outcomes Relevant to Clinical Goals and Quality Measures... 386 13.8.3 Qualitative and Quantitative Methods of Evaluation... 386 13.9 Chapter Thirteen Key Points... 388 13.10 Review Questions... 389 13.11 Answers... 394 13.12 Lifecycle Suggested Reading... 398 14 Leadership and Managing Change... 399 14.1 Leadership Models, Processes, and Practices... 399 14.1.1 Leadership Process... 401 14.1.2 Leadership Styles... 402 14.1.3 The Dimensions of Effective Leadership... 402 14.1.4 Governance... 403 14.1.5 Conflict Management... 403 14.1.6 Negotiation... 405 14.1.7 Collaboration... 406 14.1.8 Motivation... 407 14.1.9 Decision-Making... 408 14.2 Effective Interdisciplinary Teams... 409 14.2.1 HR Management... 410 14.2.2 Team Productivity and Effectiveness... 412 14.2.3 Group Management Processes... 414 14.2.4 Managing Meetings... 416 14.2.5 Managing Group Deliberations... 417 14.3 Effective Communications... 418 14.3.1 Communications Basics... 418 14.3.2 Individual & Group Presentations... 420 14.3.3 One-on-One Communication... 421 14.3.4 Effective Writing... 422 14.3.5 Communications Support for Implementation Support... 423 14.4 Project Management... 424 14.4.1 Basic Principles... 424 14.4.2 Identifying Resources... 427 14.4.3 Resource Allocation... 429 14.4.4 Project Management Tools... 430 14.4.5 Informatics Project Challenges... 431 14.5 Strategic Planning for Clinical Information Systems... 432 14.5.1 Establishing Mission and Objectives... 433 14.5.2 Assessing the Organization... 433 14.5.3 Long-Term and Short-Term Planning... 435
xi 14.5.4 Writing the Strategic Plan... 436 14.5.5 Evaluating & Implementing the Plan... 437 14.6 Organizational Finance... 438 14.6.1 The Financial Plan... 438 14.6.2 Managerial Accounting Principles... 440 14.7 Change Management... 441 14.7.1 How to Assess the Corporate Environment... 443 14.7.2 Change Management Theories... 443 14.7.3 Change Management Strategies... 446 14.7.4 Implementing Effective Change Management... 447 14.7.5 Getting Change to Stick or Refreeze... 447 14.7.6 Strategies for Systems Adoption... 448 14.8 Chapter Fourteen Key Points... 449 14.9 Review Questions... 450 14.10 Answers... 458 14.11 Recommended Reading... 466
xii Disclaimer Although the author and publisher have made every effort to ensure that the information in this book was correct at press time, the author and publisher do not assume and hereby disclaim any liability to any party for any loss, damage, or disruption caused by errors or omissions, whether such errors or omissions result from negligence, accident, or any other cause. Except as specifically stated in this book, neither the author or publisher, nor any authors, contributors, or other representatives will be liable for damages arising out of or in connection with the use of this book. This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory; direct, indirect or consequential damages; loss of data, income or profit; loss of or damage to property and claims of third parties.
xiii About this Book We re glad we can join you on your journey towards becoming a board certified clinical informatician. Our goal is to provide you with a concise presentation of the basic principles of clinical informatics in an easy to understand format. As you prepare for the exam, we hope you use this book in combination with your clinical experience as part of your toolkit. We will cover the major topics in the examination content outline, though we may have reorganized some of it in the interest of flow and clarity. Each section will focus on a core content topic. We have also recommended some additional reading at the end of most sections for those who find a topic interesting and would like to dive deeper into the material. The major sections of this book are as follows: Exam Details Clinical Informatics Overview The Health System Clinical Decision Making and Care Process Improvement Evidence Based Patient Care Workflows Analysis, Process Redesign, and Quality Improvement Health Information Technology Systems Human Factors Engineering Health Information Systems Applications Clinical Data Standards Information System Lifecycle Leadership and Managing Change Periodically, we ll update the content of this book (typically once a year). If you d like to receive notifications about these updates, please visit informaticspro.com and let us know. This is also the place to find out information regarding access to our companion set of questions to help gauge your strengths and weaknesses. This is an exciting time in the development of this new area of expertise and we hope to provide you with the knowledge it will take to become a pioneer in the field of clinical informatics. If have any comments or suggestions, please let us know at: info@informaticspro.com. Happy studying!
xiv Practice Questions & Additional Study Materials Practice Questions Each chapter in this book has review questions designed to test your understanding of the topics covered. For those interested, additional practice questions, practice exams, and other materials and resources are available on our website at www.informaticspro.com. We would like to note that it is likely that there will be differences between the questions we present and the questions on the exam. Since we cannot know for sure the style of test questions due to the confidentiality agreements, our questions will be written following the National Board of Medical Examiners guide for written test questions for the basic and clinical sciences. Additional Study Materials If you re looking for additional study materials, the clinical informatics core content outline available at http://www.theabpm.org/applicationci/ci_studyguide.pdf does include recommended reading. While it would be great if you could read all the books and journals on the list, we know that time will likely prevent you from doing so. With that being said, if you re going to read another book in addition to this one, we would highly recommend Shortliffe & Cimino s book Biomedical Informatics: Computer Applications in Health Care and Biomedicine.
xv Free Stuff! Want a free quick reference guide that covers the major concepts covered in this book? All you have to do is go to our website and sign up for our email list. We ll send you a PDF version of the quick reference guide right away, and then a handful of emails throughout the year as we get closer to the exam. Just head to www.informaticspro.com to get started.
xvi Errata While our moms may think we are, we are actually not perfect. Be sure to check out informaticspro.com/errata for any errors that apply to this book. And if you find any yourself, be sure to email us at info@informaticspro.com.
1 1. Exam Details 1.1 Topics Covered The clinical informatics subspecialty board certification exam covers a wide variety of topics ranging from leadership and change management to clinical information system implementation. Within your current studies and experience, it is likely you have touched on many of these topics while there are some you have never studies before. It is our goal to bring you up to a level of understanding and knowledge that will allow you to pass your board exam. The informatics exam covers four major topic areas: informatics fundamentals, leaning and managing change, clinical decision making and process improvement, and health information systems. In terms of topic distribution, the test should cover four main areas in the proportions depicted below in Figure 1-1. Figure 1-1. Composition of the Exam. According to ABPM, (the overseer of the exam) the questions should reflect situations potentially faced as a practicing clinical informatician. In particular, ABPM states: There are no trick questions, and it would be unusual for a question to reflect very recent events or issues (i.e., new hot topics) because of the lead time necessary to develop the full examination. The general purpose is to ascertain whether there is a sound base of specialty relevant knowledge and skills and the ability to exercise discernment and judgment. -and- The distribution of examination questions is weighted in favor of relevance to actual practice; however, candidates who are preparing to represent themselves as competent must recognize they are responsible for knowledge and skills across the breadth of their chosen subspecialty, not just in the preponderant content of their personal day-to-day practice. Examinations do not
2 stress esoteric facts, and they do require examinees to demonstrate sound understanding. A primary purpose of this outline is to describe the extent of the subspecialty. 1 The exam should not require you to memorize obscure acronyms or uncommon definitions. We will attempt to get you to a point where you can take the information presented in this book and apply it to common scenarios you may face in practice. 1.2 Requirements for Certification At time of publishing, the following are the requirements to receive a certification in the clinical informatics sub-specialty. They consist of: A medical school degree An ABMS board certification A valid medical license Completion of one of two following pathways o Practice o Fellowship The requirements outlined by ABPM include a degree, board certification, licensure and completion of one of two pathways: 2 A Degree Meeting one of the Following Criteria: A degree from a Liaison Committee on Medical Education accredited school A degree from an American Osteopathic Association accredited school A degree from an accredited medical school in Canada A degree from a medical school outside the United States and Canada deemed satisfactory to the Board ABMS Board Certification in one of the Following: The American Board of Allergy and Immunology The American Board of Anesthesiology The American Board of Colon and Rectal Surgery The American Board of Dermatology The American Board of Emergency Medicine The American Board of Family Medicine The American Board of Internal Medicine The American Board of Medical Genetics The American Board of Neurological Surgery The American Board of Nuclear Medicine The American Board of Obstetrics and Gynecology 1 The American Board of Preventive Medicine. Study Guide Materials Examinations Content Outline. ABPM website. http://www.theabpm.org/applicationci/ci_studyguide.pdf. Published March 2015. 2 The American Board of Preventive Medicine. The American Board of Preventive Medicine Clinical Informatics Board Certification www.theabpm.org
3 The American Board of Ophthalmology The American Board of Orthopaedic Surgery The American Board of Otolaryngology The American Board of Pediatrics The American Board of Physical Medicine and Rehabilitation The American Board of Plastic Surgery The American Board of Preventive Medicine The American Board of Psychiatry and Neurology The American Board of Radiology The American Board of Surgery The American Board of Thoracic Surgery The American Board of Urology The American Board of Pathology* *Note: Those certified by the American Board of Pathology must apply through ABPath. All others may apply through ABPM. 1.2.1 Licensure Applicants must possess an unrestricted and currently valid license or licenses to practice medicine in a state, the District of Columbia, commonwealth, territory, or possession of the United States, or in a Province of Canada. 1.2.2 One of the Following Pathways to Certification Through 2022, either pathway is acceptable. After 2023, applicants must complete a minimum 24-month clinical informatics fellowship accredited by ACGME. 1.2.2.1 Practice Pathway Three years of practice in Clinical Informatics is required. Practice time must be at least 25% of a Full- Time Equivalent (FTE) to be considered. Practice time need not be continuous, however, all practice time must have occurred in the five-year interval immediately preceding application for certification. 3 Practice must consist of broad-based professional activity with significant clinical informatics responsibility. Documentation of clinical informatics research and teaching activities may also be submitted for review if it includes significant clinical informatics responsibility. Verification is required that the equivalent of at least 3 years of an individual's professional time has been devoted to the practice of clinical informatics during the five years prior to application for the examination. A person or persons who are knowledgeable about the applicant s practice, such as the Chief of Staff, the applicable department chair, the director of a related clinical informatics training program, or the director of the clinical informatics program in the related institution must complete the verification. Completion of the verification by a partner or practice associate is not acceptable. The verification form will be available at the time of application. 3 The American Board of Preventive Medicine. The American Board of Preventive Medicine Clinical Informatics Board Certification www.theabpm.org
4 For those who completed non-accredited fellowship training of less than 24 months, the fellowshiptraining curriculum as well as a description of the actual training must also be submitted. The applicant must submit evidence of additional practice to satisfy any additional Practice Pathway requirements. 1.2.2.2 Fellowship Training Pathway For those taking the fellowship pathway, completion of a fellowship program of at least 24 months in duration that is ACGME accredited is required. As of late 2016, programs with an ACGME certified clinical informatics program include: Beth Israel Deaconess Medical Center Boston Children s Hospital Case Western Reserve University The Children s Hospital of Philadelphia Columbia University David Geffen School of Medicine at UCLA and UCLA Health Duke University Geisinger Health System Madigan Army Medical Center Massachusetts General Hospital Ohio State University Oregon Health & Science University School of Medicine Regenstrief Institute, Inc. Stanford School of Medicine SUNY - University at Buffalo The University of Arizona College of Medicine Phoenix University of California San Diego University of California San Francisco University of Illinois at Chicago College of Medicine University of New Mexico University of Washington Vanderbilt University Medical Center Program Yale University Washington University in St. Louis As clinical informatics grows and matures, expect to see this list expand. In fact, it may have expanded between the time this book was printed and when you re reading it, so be sure to check out the ACGME website at https://apps.acgme.org/ads/public/reports/report/1 to search for accredited fellowships.
5 1.3 Exam Day 1.3.1 The Exam Format The exam is a computer-based exam consisting of 200 equally weighted multiple-choice questions with a four-hour time limit. There are no penalties for guessing or leaving an answer blank. Here is an example of the question format: The IOM core value for efficiency is best exemplified by the following statement: 1. Resources are optimized to allow for the largest number of patients to be seen by a clinician. 2. Human and physical resources are managed in ways that minimize waste and optimize access to appropriate treatment. 3. Goal-directed services are promptly provided in order to restore and sustain the integration of clients and families into the community. 4. The prevention of patient harm in a timely matter. Question types may include: Clinical vignettes Experimental or statistical observations Definitions or classifications Administrative problems Applications of principles or regulations Any other scenario that may be seen in practice Following basic testmanship, if you don t know the answer, eliminate the improbably answers and then take your best guess from the remaining possibilities. Do not leave any questions blank, as every question is weighted equally and there are no penalties for incorrect answers. If you re unsure of a question, you can mark it and come back to it at the end of the exam if time permits. Before the test questions begin, there will be an optional tutorial on how to use the computer based testing system. You can choose to click through it quickly to get to the questions, go through it thoroughly to understand the system, or you can choose to use the time for a brain dump before beginning the exam. A tutorial for the computer-based system is available at http://measurementresearch.com/testing/tutorial.shtml. 1.3.2 Registering for the Exam To be eligible to take the exam, individuals are required to fill out an application and pay a non-refundable application fee. If it is determined you meet the requirements, you will then have to pay an examination fee. Once these two steps are complete, applicants will receive a confirmation letter from which they can register for the exam either through Pearson VUE or the ABPM s registration hotline at 877-392-3926. Please make sure that you check with ABPM for the latest details, since cancellations or deferrals occurring before the cancellation date will incur an administrative fee. Cancellations occurring after the cancellation date will not receive a refund or deferral.
6 1.3.3 The Exam Location Testing is done at Pearson VUE locations across the US. You may choose which one is most convenient for you. Be sure to arrive 30 minutes early for your exam. Late arrivals will forfeit their seat. It is also strongly recommended that you bring several forms of ID with you just in case and your confirmation letter. Pearson VUE is strict with their identification policy and will not let you take the exam if you can t prove who you say you are.
7 1.4 Chapter One Key Points The primary topics on the exam include fundamentals, leading and managing change, clinical decision making and process improvement, and health information systems To apply for the exam, the applicant must be a currently licensed and board certified physician in the US or Canada with a fellowship in informatics or relevant experience. The latter route closes in 2023. Testing is done on the computer at PearsonVUE locations. Be sure to bring a copy of your exam confirmation and identification.
8 2 Clinical Informatics Overview Clinical Informatics is the application of informatics, clinical knowledge, and technology to continuously improve healthcare systems, services, and outcomes. It seeks ways to: Better assess, design, implement, and evaluate clinical information systems for providers, patients, and administrators Understand, evaluate, and re-engineer clinical processes so they may improve the quality of healthcare and create efficient and effective workflows Lead and manage organizations through times of change especially through information technology (IT), clinical, regulatory, and health system changes Improve the clinical decision making process As depicted below in Figure 2-1, clinical informatics as a discipline resides at the intersection of three major domains: the health system, clinical care, and information & communications technology. Clinical care concerns the clinical care of patients, clinical decision-making, and clinical workflows. The health system concerns managing individual and population health, the regulations and requirements of the healthcare system, health economics and financing, and managing and improving the quality of care. Information and communications technology concerns computer systems, architecture, networks, and other technical underpinnings of clinical information systems that keep health care systems up and running. Figure 2-1. Clinical Informatics as it Relates to Other Disciplines. 2.1 What is a Clinical Informatician? According to the American Medical Informatics Association, a clinical informatician is someone who transforms healthcare by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care,
9 and strengthen the clinical-patient relationship. 4 Essentially, a clinical informatician is a change agent to help bring information technology to the clinical domain. 2.2 Informatics History The recording of healthcare data has been around since Hippocrates first developed the medical record in the fifth century. 5 Since then, records have evolved from tablets and paper ledgers to electronic repositories. However, over the course of health record development, there has never been a standard patient record. Configurations, units of measurement, and style of recording have made the conversion from written record to electronic health record one of the greatest challenges in the health information technology industry. We are making significant process towards interoperability in healthcare using technology, standards, best practices, new research, regulations, and informed stakeholders. Fifty years ago, the first research on diagnostic decision-making, Reasoning Foundations of Medical Diagnosis, reviewed methods that could be used where risk and uncertainty existed. 6 This paper began the conversation on computer-based clinical decision support. Following this, additional papers were published in the mid-80 s that included topics in medical informatics frameworks, functional and architectural considerations for clinical information systems, medical research analysis, and standardizing electrocardiogram analyses from computers. 7 In terms of informatics, the use of computer technology in the early 1950s began to influence the field of medicine and the first health informatics organizations were born. The first of which was founded in Germany during 1949, with more and more beginning to appear during the 1960s and 70s across Europe and the United States. The largest and most prominent professional organization from this time is the International Medical Informatics Association (IMIA). AMIA (American Medical Informatics Association) is also a large a growing professional organization for informatics professionals in the United States. 2.2.1 A History of the Clinical Informatics Subspecialty In 1989, the American Medical Informatics Association (AMIA) was formed as the United States representative to IMIA through the integration and merging of the following informatics organizations: American Association for Medical Systems and Informatics American College of Medical Informatics Symposium on Computer Applications and Medical Care Its mission is to lead the way in transforming health care through trusted science, education, and the practice of informatics. In 2005, AMIA began the process to make clinical informatics a recognized subspecialty by the American Board of Preventative Medicine. Below you can see the timeline of the clinical informatics subspecialty s development. 4 Garner, R.M., Overhage, J.M., Steen, E.B., Munger, B.S., Holmes, J.H., Williamson, J.J., Detmer, D.E. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association. Vol 16 No 2. DOI 10.1197 5 National Institutes of Health National Center for Research Resources (2006). Electronic health records overview. www.himss.org 6 Ledley, R.S. and Lusted, L.B. Reasoning Foundations of Medical Diagnosis. Science. 130 (1959) 9021. 7 Haux, R. Medical informatics: past, present, future. International journal of Medical Informatics. 79 (2010) 599-610.
10 Figure 2-2. Timeline for the Evolution of the Clinical Informatics Sub-Specialty. The first class of diplomates received their certification in 2013. The 2017 exam will produce only the fifth cohort of certified clinical informaticians. 2.3 Domains of Informatics As you might expect from a field with the diversity and quantity of influences as medical informatics, the domains and subspecialties associated with clinical informatics are equally varied. Some of the major domains in medical informatics are translational bioinformatics, imaging informatics, clinical informatics and public health informatics. We ll briefly review each of these domains, though this is just a small sampling of a growing set of domains. Figure 2-3. Domains of Informatics. 2.3.1 Translational bioinformatics Translational bioinformatics is concerned with the development of methods to optimize the transformation of huge amounts of data, such as those from genetic analyses. This is one example of big data and mining of such big data to obtain new knowledge. As you might expect, as we develop methods to store large amounts of data we have to develop corresponding techniques to enable us to analyze this type of data more effectively. This is the realm of translational bioinformatics. Although translational bioinformatics may at some point influence clinical informatics through their results, it s not precisely clinical informatics. 8 8 AMIA. Translational bioinformatics. www.amia.org
11 2.3.2 Imaging informatics Imaging informatics, or radiology informatics is concerned with the efficiency, accuracy, and reliability of radiologic services within the medical enterprise. 9 Picture Archiving and Communication Systems (PACS) and other imaging solutions, combined with EHRs and Health Information Exchanges (HIEs) have allowed the field of imaging informatics to grow into its own subspecialty of diagnostic radiology. Imaging informaticians may seek new ways to process and compress images, integrate images into EHRs, mine data from image databases, enhance images, create vocabularies, ontologies, and more. Radiologists may undergo an imaging informatics fellowship if informatics is a field of interest to them. 2.3.3 Public health informatics Public health informatics shares some aspects of translational bioinformatics in that it is concerned with the analysis of large sets of data. However, public health informatics focus is to promote and support areas of public health. Some of the unique challenges of public health informatics are the integration of large sets of data that come from disparate sources. This is one of the touch points to clinical informatics because the source of much of the public health informatics data comes from clinical systems. We will discover and discuss in subsequent sections the importance of and strategies for the implementation of standardized data, standardized messaging, and standardized transactions. 2.3.4 Clinical informatics With the many domain of informatics, you can see that clinical informatics is only one facet of a number of healthcare informatics domains. Clinical informatics varies from many of the other informatics domains in that it couples clinical information systems and the data they produce with the way decisions are made, how leadership and management affect change, and how data and information systems can be used to provide better clinical care. 2.4 Informatics as a Career Clinical informaticians work at the intersection of the health system, clinical care, and information and communications technologies. Typically, physician clinical informaticians may hold positions as: Chief Medical Information Officers (CMIO) Chief Medical Officers (CMO) Chief Information Officers (CIO) Chief Executive Officers (CEO) Researchers Vendor representatives Consultants Departments heads Professors Fellowship directors Health IT project managers 9 Branstetter, B (2007). "Basics of Imaging Informatics". Radiology 243 (3): 656 67. doi:10.1148/radiol.2433060243
12 Healthcare focused software engineers & developers Directors of health informatics Clinical informatics analysts and specialists And other positions that need leaders to merge health IT and clinical knowledge Whether you re already a CMIO or are seeking certification to improve your knowledge base, there are many ways to get involved in the informatics community. You may want to join an existing community within a professional organization (see below), create your own community, or pair your certification with another outside qualification. Some online communities you can get involved with include: Doximity CMIO Group: LinkedIn Clinical Informatics Leadership Group LinkedIn Clinical Informatics Board Exam Prep 2.4.1 Interest Groups Within the informatics subspecialty, there are numerous specialized interests and working groups you can get involved in. Whether you re a big proponent of open source software, would like to improve the health of your region using informatics, or enjoy the organizational management challenges that come with running complex IT systems, there is some way for you to get involved with the informatics community. Table 2-1 lists a sampling of some of the community and workgroup areas within AMIA: Table 2-1. Informatics Communities. Interest Technology Research & Education Specialty Informatics Leadership, Management, and Social Impact Communities and Workgroups Clinical Decision Support Clinical Information Systems Natural Language Processing Knowledge Representation and Semantics Open Source Knowledge Discovery and Data Mining Visual Analytics Clinical Research Informatics Informatics Education Biomedical Imaging Informatics Genomics Dental Informatics Nursing Informatics Pharmacoinformatics Consumer and Pervasive Health Informatics Global Health Informatics Regional Informatics Primary Care Informatics Genomics and Translational Bioinformatics Intensive Care Informatics Public Health Informatics Ethical, Legal, and Social Issues in Informatics People and Organizational Issues Informatics Evaluation
13 2.4.2 Professional Organizations Joining a professional organization can help ease your transition into becoming a practicing informatician by offering networking opportunities, professional development, and dedicated job boards. Some informatics specific and related ones include: American Health Information Management Association (AHMIA) American Medical Informatics Association (AMIA) Canadian Health Information Management Association (CHIMA) Health Information and Management Systems Society (HIMSS) International Medical Informatics Association (IMIA) 2.4.3 Professional Certifications As you investigate the health IT space and explore the individuals that make up our community, it is likely that you will find that some of them have unfamiliar credentials listed after their names. Here is a quick rundown of other relevant certifications: American Nurses Credentialing Center (ANCC) Informatics Nursing Specialty Certified Associate in Healthcare Information and Management Systems (CAHIMS) Certified Health Data Analysis (CHDA) Certified Professional in Healthcare Information and Management Systems (CPHIMS) Certified Scrum Master (CSM) Certified Professional in Health Information Technology (CPHIT) Certified Professional in Electronic Health Records (CPEHR) Certified Professional in Health Information Exchange (CPHIE) Certified Professional in Operating Rules Administration (CPORA) CompTIA Healthcare IT Technician Healthcare Information Security and Privacy Practitioner (HCISPP) Information Technology Infrastructure Library (ITIL) Project Management Professional (PMP) Registered Health Information Administrator (RHIA) 2.5 Current and Future Challenges for Informatics The challenges today and tomorrow for medical informatics lie in several areas. The most prominent of which are interoperability, usability, patient engagement, and ubiquitous care. 2.5.1 Interoperability As we will discuss in detail later in this book, interoperability is a foundational enabling component of nearly everything in healthcare IT. Without interoperability, our EHRs are merely electronic versions of our old paper system. 2.5.2 Usability For health record systems to be useful, they must be usable. Usability is a challenge on many fronts because current electronic health records rely upon providers encoding information into the system. Forcing clinicians to take time from their interaction with the patient to essentially encode their diagnoses
14 in a machine-readable format is unnatural to many. This is often cited as one of the primary reasons for physician reluctance and resistance to adopting clinical information systems. Resistance to adoption results in workarounds that often defeat the originally intended purpose. For example, many physicians choose to dictate free text into the note area of their health record, as opposed to codifying their information in templates that have been provided. Another common workaround is scanning paper records into the patient s electronic record. Although these are readable by other humans they re not computable in the sense that useful data cannot be extracted from them in a consistent fashion (though natural language processing research is improving this). So, improving the usability of our electronic health records is the first step in gaining physician adoption and enabling the collection of standardized and reliable sets of information from all our patients. This is foundational to realize the true benefit of clinical information systems. 2.5.3 Patient engagement Along with the challenges of physician adoption are the challenges of patient adoption. As we move from a fee-for-service payment model to a value-based model where patient engagement will be critical, having reliable systems that the patient can use will be equally critical. The challenges in this area stem from security of health data, the legal and regulatory systems in place to help us navigate responsibilities in a patient centered care environment, and the technology to consistently and reliably collect data from disparate sources (e.g., home blood pressure monitors, fitness trackers, etc.). This last category of patient adoption falls within the realm of what s been referred to as individualized medicine. As our technology improves in terms of being able to rapidly sequence an individual genome, so too must our ability to not only make predictions and recommendations for an individual based upon the data, but also how we handle this data from an ethical standpoint. 2.5.4 Personalized medicine Personalized medicine or precision medicine is healthcare customized for the individual patient. Genetics and biological variation in each of us may affect which diseases we are prone to and which drugs are most effective for our conditions. With precision medicine, a patient s individual DNA, RNA, and proteins may be sequenced and analyzed to paint a broader picture of the patient s health, determine which diseases they are at higher risk for, and how likely they may be to respond to particular treatments. This advanced level of healthcare using previously unavailable data may reduce a patient s risk of disease, increase prevention and proactive care, and help us best treat disease when it does occur. 2.5.5 Ubiquitous care The final category of future challenge is that of ubiquitous care. This encompasses a wide range of challenges, from being able to integrate large sets of data between various data sources and rapidly consolidate that information based upon patient identification, to our ability to widely disseminate changes in healthcare recommendations and care guidelines to all clinicians. This category in many ways is the goal of clinical informatics.