1. Raymond D. Aller, M.D. Director of Informatics USC Pathology 20 September 2010 Training in Pathology Informatics: Lecture, Project, Rotation, Fellowship and beyond

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

3. 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

4. More recently, it gets better ... • Ongoing fellowships • General medicine rediscovers board certification • Advertising for these skills

5. The explorers • Bill Dito, Art Rapapport, George Brecher, Homer Warner, Phil Hicks, many others • Self taught • From basic data management to deeper analysis

6. 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

7. 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

8. 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.

9. 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

10. 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

11. “Just in time” knowledge • Calling your friends • Local colleagues • Google, Wikipedia, etc • API listserv

12. 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”)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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...

20. 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.

22. 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”

23. 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

24. 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

25. 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?

26. 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

27. 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.

28. 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.

29. 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.

30. How many faculty? • .. at least 40% time doing informatics (service, research, teaching, etc) • One, one, two, two + six, 5, 14

31. 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

32. Number of fellows - Many programs - zero much of the time Some programs, one Another, five

33. 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)

34. 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"

35. 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

36. General medical informatics programs • Interaction with NLM funded general medical informatics fellowship? • MGH - available, but not best option • Some others – not available

37. 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.”

38. 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”

39. 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

40. Effect on faculty workload Faculty time Weeks -->

41. 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

42. 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.

43. 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

44. 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

45. 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.

46. 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.

47. 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.

48. 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

49. Service work Myriad: • system maintenance, • issues resolution, Training of staff and residents No on call per se Image analysis Diagnostic pathology (e.g., surgical pathology, cytopathology) Clinical pathology (e.g., transfusion medicine)

50. 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