Early experiences with combined fellowship training in clinical informatics

Abstract

Given the ubiquitous nature of information systems in modern health care, interest in the pursuit of formal training in clinical informatics is increasing. This interest is not restricted to generalists—informatics training is increasingly being sought by future subspecialists. The traditional structure of Accreditation Council on Graduate Medical Education subspecialty training requires completion of both clinical and clinical informatics fellowship programs, and understandably lacks appeal due to the time commitment required. One approach to encourage clinical informatics training is to integrate it with clinical fellowships in order to confer dual-board eligibility. In this perspective, we describe 3 successful petitions for combined training in clinical informatics in order to support other programs and the American Board of Preventive Medicine in establishing pathways for training subspecialists in clinical informatics.

INTRODUCTION

Clinical informatics (CI) is a nontraditional subspecialty first recognized by the American Board of Medical Specialties in 2011, and the practice of CI is described as the analysis, design, implementation, and evaluation of information systems to improve patient care and outcomes.^1,2 The first fellowship training programs certified by the Accreditation Council on Graduate Medical Education (ACGME) were established in 2014,³ and since that time the number of programs has grown to >40.⁴ According to the ACGME, it is a “subspecialty of all medical specialties,” in that completion of any core residency program confers eligibility for CI fellowship training.⁵ However, the special requirements of electronic health records (EHRs) differ by medical specialty, and subspecialties often have even more particular needs.^6–12 The practice of CI can therefore benefit from formally trained subspecialists to advocate for and help build tools that address unique workflows and share them broadly. The traditional structure of ACGME-accredited subspecialty training requires completion of both clinical and CI fellowship programs; an additional 2 years of fellowship understandably lacks appeal to those already committing to clinical subspecialty training.

One approach to encourage CI training is to integrate it with clinical fellowships, such that a blended curriculum can be completed with only 1 additional year of postgraduate medical education. Some certifying boards offer dual enrollment pathways that allow for completion of 2 subspecialty certifications within the same board^13,14; the American Board of Pathology, one of the certifying boards for CI, offers such pathways.¹⁵ However, board eligibility following combined fellowships in CI for nonpathologists requires the approval of 2 specialty boards: a clinical board (eg, American Board of Internal Medicine) and the American Board of Preventive Medicine (ABPM). Notably, the ABPM allows surgical residents to complete CI fellowship and sit for the boards before completing surgery residency, with the stipulation that board certification in CI is contingent on board certification in surgery.¹⁶

We successfully petitioned the ABPM and clinical specialty boards to create 3 distinct combined training programs that confer dual-board eligibility. Here, we detail the nuances of the 3 approaches in an effort to support program directors and fellowship applicants interested in combining CI fellowship with clinical subspecialty training.

DESCRIPTION OF COMBINED PROGRAMS

A summary of the 3 programs is provided in Table 1 and Figure 1.

Table 1.

Summary of clinical informatics programs and combined training

CI Program and Combined Fellow	Clinical Specialty and Certifying Board (Years of Training)	Petition Timeline	Combined Program Structure
Boston Children’s Hospital Joshua Herigon, MD, MPH	PID, ABP (3)	1/2018: Initial petition 5/2018: ABP initial response 7/2018: ABP final approval 8/2018: ABPM initial response 3/2019: ABPM approval	7/2017 (Y1): PID fellowship 7/2018 (Y2): CI fellowship 7/2019 to 6/2021 (Y3-4): Combined training
Children’s Hospital of Philadelphia Adam Dziorny, MD, PhD	PCCM, ABP (3)	7/2016: GME Committee approval 7/2016: ABP petition 8/2016: ABP approval 8/2016: ABPM petition 10/2016: ABPM approval	7/2016 (Y1): PCCM fellowship 7/2017 (Y2): CI fellowship 7/2018 to 6/2020 (Y3-4): Combined training
Stanford University Sanaa Suharwardy, MD	MFM, ABOG (3)	8/2017: ABOG petition 9/2017: ABOG approval 4/2018: ABPM petition 7/2018: ABPM initial response 3/2019: ABPM approval	7/2017 (Y1): CI fellowship 7/2018 to 6/2021 (Y2-4): Combined MFM/CI fellowship

ABOG: American Board of Obstetrics and Gynecology; ABP: American Board of Pediatrics; ABPM: American Board of Preventive Medicine; CI: clinical informatics; GME: Graduate Medical Education; MFM: maternal-fetal medicine; PCCM: pediatric critical care medicine; PID: pediatric infectious diseases; Y: year.

Figure 1.

Structure of combined programs. (A) Children’s Hospital of Philadelphia: clinical informatics (CI) blocks contain 2-3 shifts/month of pediatric critical care medicine (PCCM) clinical time. Underlying blocks represent CI research (in year 1) and PCCM clinical time (in year 2). (B) Boston Children’s Hospital: underlying blocks represent pediatric infectious diseases (PID) clinical rotations (wide) and clinics (narrow). (C) Stanford University: year 1 included approximately 20% clinical time in obstetrics. Underlying blocks represent combined research rotations. MFM: maternal-fetal medicine.

Children’s Hospital of Philadelphia

The Children’s Hospital of Philadelphia (CHOP) CI fellowship was accredited by the ACGME in 2015. The first CHOP fellow to express interest in combined CI training had an undergraduate degree in computer science, a doctorate in biomedical engineering, and was Chief Resident at CHOP before being accepted to the Pediatric Critical Care Medicine (PCCM) Fellowship in July 2016. The fellow (under the direction of the PCCM program director, the Clinical Informatics program director, and the CHOP Graduate Medical Education [GME] Office), explored options for integrated training with the American Board of Pediatrics (ABP) and ABPM.

The initial proposal to the ABP and ABPM included the first year with a primary focus on PCCM, the second year with a primary focus on CI, and the final 2 years alternating rotations in CI and PCCM every 3 months with integrated research, scholarly, and other project activities (Supplementary Appendix A). In order to maintain and grow clinical skills, clinical on-call requirements continued throughout the 4 years.

After approval by the CHOP GME Committee in July 2016, the ABP approved the 4-year time frame per their “subspecialty fast-tracking” policy,¹⁷ specifically mentioning the candidate’s PhD, the proposed integrated scholarly activity, and that the fellow would not be away from clinical training for more than 12 months. In October 2016, the ABPM approved on the condition that the fellow demonstrate a full 2 years of CI training.

Boston Children’s Hospital

The Boston Children’s Hospital (BCH) CI fellowship provides training through clinical and technical rotations with integrated coursework through the Harvard Medical School Biomedical Informatics training program. The GME office at BCH has a wealth of experience developing specialized training programs across disciplines, both within single and across multiple specialty boards.

The first fellow to combine clinical informatics training at Boston Children’s Hospital started as a fellow in pediatric infectious diseases (PID). During their first year of subspecialty training, they identified informatics as an area of interest, and the program directors from CI and PID met to explore the possibility of an integrated training program. Similar to most pediatric subspecialty fellowships, PID begins with a predominantly clinical year followed by 2 years of primarily research. This structure lends itself to combining with other training programs. We opted to make the second year of training primarily informatics, with the final 2 years focused on combined project and research time (Supplementary Appendix B). The initial combined training proposal was “viewed favorably” by the ABP; however, they encouraged distributing clinical time more evenly across the final 3 years to help the fellow maintain clinical competency. The ABPM approved the combined training as an integrated training experience (ITE).

Stanford University

The program at Stanford University (SU) was the first ACGME-accredited CI fellowship in the nation.³ SU’s combined fellow began training in CI fellowship, but declared an interest in subspecialty training in maternal-fetal medicine (MFM). She was encouraged to apply to SU’s ACGME-accredited MFM fellowship program during her first year of CI fellowship (July 2017). The proposed combined training included year 1 in CI and years 2-4 in combined MFM-CI (Supplementary Appendix C). Two months per year in years 2-4 of training were allotted to dedicated CI rotations, with the remainder of CI board eligibility requirements met through combined research and participation in CI didactics.

Approval for the combined fellowship was sought first from the American Board of Obstetrics and Gynecology Division of Maternal-Fetal Medicine. In September 2017, American Board of Obstetrics and Gynecology affirmed that completion of the proposed schedule would meet ACGME requirements for board eligibility and congratulated the programs on their innovative combination of training. The proposal was subsequently approved by the ACGME Obstetrics and Gynecology Review Committee’s Executive Committee. Having secured approval from the clinical board, the ABPM was petitioned in April 2018. In July 2018, the ABPM’s Chair for the CI subboard agreed that the proposed training would meet the requirements for initial board eligibility. This decision was upheld by the ABPM Board of Directors in March 2019, who approved the combined training as an ITE.

LESSONS LEARNED

Petition logistics

In order to allow for ample time to fulfill the requirements of both fellowships, petitions for combined training should be made within the first year of fellowship. Partnership with the program director of the clinical fellowship and local GME office is crucial for crafting a blended curriculum that satisfies the requirements of both fellowships. Each of the 3 programs described previously first sought approval for combined training from the associated clinical subspecialty board. Because clinical subboards are generally more well established than the nascent CI subboard of the ABPM, they have more experience with combined training models. We anticipated that this would make them more receptive to our proposals for combined training with CI.

Candidate selection

In all 3 cases, fellows initially applied and were accepted to a single program. Whether this was in the clinical specialty (BCH, CHOP) or CI (SU), each fellow was required to apply formally to the second program in order to be considered for combined training. We recommend application to the second program during the first year of fellowship training in order to facilitate collaboration between programs, drafting of a combined curriculum, and a timely petition to both boards.

Fellowship structure

At CHOP and BCH, the first year of training was in the clinical subspecialty, while at SU the first year of training was in CI. Generally, the second year of training predominantly comprised the second of the combined fellowships, with the remaining (third and fourth) years representing a combination of disciplines. Each program requires experiential rotations (both clinical and informatics), didactic education, and scholarly activity.

Given that clinical and informatics rotations do not naturally lend themselves to blended training, additional strategies for meeting the requirements of both programs were necessary. This was most often achieved by utilizing combined research months and elective time.

Scholarly Activity

The component of fellowship training that most naturally lends itself to integrated training is scholarly activity. An appropriate scholarly project can satisfy the requirements of both a clinical and CI fellowship. Scholarly oversight of a fellow’s work becomes the responsibility of both programs. Combined research requires an informatics mentor, and mentorship from both fellowship programs helps ensure a fellow is progressing toward meeting the scholarly activity requirements of both programs.

Electives

Blocks typically allocated for elective time during the clinical program have the potential to be used as time to complete clinical informatics experiential rotations. For example, in the SU combined program, elective months during the MFM curriculum were designated for core CI rotations.

Clinical Time

Another opportunity for meeting the requirements of both programs relates to clinical time. While there is no strict requirement for the amount of clinical time for CI fellows, recognizing the importance of practicing in the informatics environment and continuing to develop clinically, an expectation of 20% clinical time is common among CI programs. This can certainly be satisfied through rotations in the clinical fellowship. In addition, 2 programs (BCH and CHOP) received feedback from the clinical board regarding the importance of integrating clinical practice opportunities throughout the combined training experience.

Didactics

It is important to note that the didactics requirements of both programs must be met over the duration of combined training. In our examples, this is achieved by requiring fellows to attend didactics for the respective program during years or rotations dedicated to that program. In the case of combined years and rotations, certain core didactic and programmatic activities remain required, and fellows are encouraged to attend both sets of didactics as their schedule permits.

FUNDING

While financial support for clinical fellowships may be somewhat more well established and standardized, funding sources for clinical informatics fellowship programs are quite varied.¹⁸ Regardless of funding source, opportunities for shared savings exist when completing 5 years of training over 4 years.

CONCLUSIONS

We demonstrate 3 examples of successful petitions for combined fellowship training with CI across 3 distinct clinical specialties representing 2 different certifying boards. It is particularly important to develop informatics expertise within clinical subspecialties, given the unique needs of their information systems. Combined training in CI incentivizes this type of training by allowing fellows to complete training in 1 less year.

Local partnership with our institutional GME offices and coordination with program leadership from the associated clinical fellowship was critical to the success of our petitions. We believe that in all cases, initial approval by the clinical board facilitated approval by the ABPM. Each of our petitions also clearly identified at least 24 months of fellowship that fulfilled CI board requirements.

It is possible to combine training whether the first year of training is in the clinical fellowship (BCH, CHOP) or in CI (SU). In all of our examples, fellows began training prior to approval of a combined curriculum, but they were encouraged to do so based on their career interests despite ambiguity surrounding future board eligibility in clinical informatics. None of our examples included prospective consideration of applicants for both programs, but it is possible to involve both programs in the interview process if a candidate declares an interest in combined training.

While the ABPM has approved petitions for ITEs between CI and clinical subspecialties, it is unrealistic for them to partner with all clinical boards to establish formal pathways for combined training in informatics. It would therefore be useful for the ABPM to publish guidelines for establishing new ITEs. Here, we outlined 3 successful approaches to combined training in clinical informatics, and our hope is that this article will serve as a guide to support fellows and program directors in future petitions for integrated training.

AUTHOR CONTRIBUTIONS

JPP conceived of the manuscript. JPP, JDH, and AAL each contributed to the design of the manuscript, drafting of the article, and critical revisions, and approved the final version.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Journal of the American Medical Informatics Association online.