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Informatics

Authors

Zachary Jarou, MD
President, EMRA Board of Directors
Member, ACEP Public Relations Committee
ACEP Fellowship in Administration, Quality, Informatics, and Policy
University of Chicago Administrative Fellowship

Abdulaziz S. Alhomod, MD
Emergency Medicine Physician
Clinical Informatics Fellow
Oregon Health & Science University

Faculty Editor

James Killeen, MD, FACEP
Clinical Professor of Emergency Medicine
Clinical Informatics Fellowship Director
Departments of Emergency Medicine and Biomedical Informatics
UC San Diego Health

Special thanks to our 1st edition writing team

Krystle Shafer, MD
Warren M. Perry, MD

INTRODUCTION

Description of the specialty
The Accrediting Council for Graduate Medical Education (ACGME) defines this fellowship as “the subspecialty of all medical specialties that transforms health care by analyzing, designing, implementing, and evaluating information and communication systems to improve patient care, enhance access to care, advance individual and population health outcomes, and strengthen the clinician-patient relationship.”

History of the specialty/fellowship pathway
In 2007, the American Medical Informatics Association launched an investigation to define the core content and training process for proposed informatics fellowship. In 2008, they sent proposals to multiple different medical specialty boards, and in 2009 the American Board of Preventive Medicine (ABPM) agreed to sponsor the fellowship. In 2010, the formal application was submitted, and in 2011 the ABPM committee officially accepted it. Starting in 2013, the newly created board certification exam became available to physicians already working in the field of informatics to become certified through the “Practice Pathway.” There are 2 options to be considered eligible for the practice pathway:

  • Obtaining a 24-month master's or doctoral program in Biomedical, Health Sciences, or Clinical Informatics
  • 3 years of 25% FTE work in Clinical Informatics (10 hours per week minimum) within the past 5 years, which may include time spent completing a non-ACGME fellowship.

Eligibility for practice pathway will not be available after 2022, and thereafter only graduates of Clinical Informatics Fellowships will be eligible for board certification.

Why residents choose to follow this career path
This training path is for those physicians who are interested in the application of information technology and protocols to promote efficient patient care, improve access to data, and help prevent disease. 

How do I know if this path is right for me?
Are you interested in the use of technology to help facilitate care for patients and assist with patient safety? Do you wish to design an interface between health care systems and providers that is more user-friendly? Are you interested in creating a strategy, budget, and team to introduce new technology to a health care system? If the answer is yes, this may be the fellowship for you.

Career options after fellowship
Career options include: chief information officer (CIO), chief medical information officer (CMIO), physician champion for patient safety, quality improvement project leader, and risk management director.

Splitting time between departments
After being certified in informatics, physicians traditionally use their information training as part of their administrative duties while still maintaining clinical duties.  

Academic vs. community positions
Due to the introduction of electronic health records, it is certainly possible to use your informatics training at a community or academic institution. Some informatics physicians may prefer employment at a low volume community hospital, where as others may prefer employment at a large research focused academic institution. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Clinical Informatics Fellowships are sponsored by a wide variety of specialties; however, most are willing to accept residency graduates from any primary specialty. As of April 2018, there are 31 ACGME-accredited fellowships:

Emergency medicine applicants open to a non-ACGME fellowship, may also be interested in applying to the “Administration, Quality, Informatics, and Policy Fellowship” co-sponsored by the American College of Emergency Physicians (ACEP) and Integrated Emergency Services (IES) based in the Dallas/Fort Worth, Texas area. The first year of fellowship will provide a mentored experience in four 3-month blocks related to administration, quality, informatics, and policy. The second year of training will allow the fellow to focus on one of the four domains explored during the first year. And a third year of training is option for applicants who wish to complete an MBA or MPH. At ACEP, fellows will have the opportunity to work with ACEP’s Clinical Emergency Department Registry (CEDR), develop national quality measures, and/or develop national policies for the field emergency medicine. At IES, fellows will be involved in departmental quality projects and administrative issues across the network of hospitals staffed by IES. Time spent in this program can be applied toward board-eligibility in Clinical Informatics via the practice pathway. Interested applicants should contact Pawan Goyal, MD at pgoyal@acep.org.

Differences between programs
As demonstrated by the growing list of ACGME-accredited Clinical Informatics fellowships, programs can be sponsored by departments of anesthesia, emergency medicine, family medicine, internal medicine, pathology, and pediatrics. Applicants should definitely consider programs sponsored by their primary specialty, but emergency medicine residency graduates should not limit themselves to only the four fellowships sponsored by departments of emergency medicine. Applicants should ask if programs sponsored by other specialties have had emergency medicine fellows before, and if so what types of projects they have worked on to ensure that they will gain experience specific to emergency medicine, rather than being limited to inpatient or outpatient informatics projects. Also, given the breadth of clinical informatics, applicants should learn which areas the institution has the most expertise in. 

Length of time required to complete fellowship
The ACGME requires a 2-year fellowship.

Skills acquired during fellowship
During fellowship, you will receive training in each of the four core content categoriesthat serve as the blueprint for the Clinical Informatics board-certification examination:

  1. Fundamentals
    1. Clinical Informatics
    2. The Health System
  2. Clinical Decision Making and Care Process Improvement
    1. Clinical Decision Support
    2. Evidence-based Patient Care
    3. Clinical Workflow Analytics, Process Redesign, and Quality Improvement
  3. Health Information Systems
    1. Information Technology Systems
    2. Human Factors Engineering
    3. Health Information Systems and Applications
    4. Clinical Data Standards
    5. Information System Lifecycle
  4. Leading and Managing Change
    1. Leadership Models, Processes, and Practices
    2. Effective Interdisciplinary Teams
    3. Effective Communications
    4. Project Management
    5. Strategic and Financial Planning for Clinical Information Systems
    6. Change Management

Typical rotations/curriculum
Example of rotations include the following: clinical informatics experience managing an electronic health record; reporting and analytics; quality improvement training and project involvement; research; and electives such as interoperability with your local or regional health information exchange (HIE) organization. Additionally, most fellowships provide fellows with protected time to practice in their primary specialty to maintain their clinical skills (aka must maintain primary specialty skills/certification by working in that respective department).

Board certification afterwards?
Yes. This exam is conducted by the American Board of Preventive Medicine. 

Average salary during fellowship
Because this is an ACGME fellowship, salary is based on the appropriate PGY level. 

PREPARING TO APPLY

How competitive is the fellowship application process?
Currently there are 31 ACGME-accredited programs (4 based in departments of emergency medicine) with each typically taking 1-2 fellows per year. 

Requirements to apply
You must be board eligible or board certified in any ABMS approved specialty to apply. 

Research requirements
Research is not required but is highly recommended, especially if the research is completed on a topic relevant to informatics. Make sure you have your research projects near completion when you apply. It is better to have one completed research project than three projects in the data collection phase. 

Suggested elective rotations to take during residency
Consider using your elective time to take an administrative or research elective. Some programs specifically have an informatics rotation, which would be an ideal rotation. Residents at hospitals or health systems using Epic might also consider asking their institution to register them to attend "Physician Builder" courses at the Epic Intergalactic Headquarters in Verona, Wisconsin.

Suggestions on how to excel during these elective rotations
Your elective months can potentially connect you with attending physicians who may be your future letter of recommendation writers. Thus, it is imperative to treat every day on elective as an interview day. Treat everyone with respect and go the extra mile. It is always looked at positively when you arrive early and stay late to help. Be innovative. Strive to be both a team player and a leader. Read every night, and increase your knowledge base about informatics. 

Should I complete an away rotation?
It may be worth considering an away rotation at a program that has an informatics fellowship. This may be a prime way to help “get your foot in the door” and display your interest and clinical skills.

What can I do to stand out from the crowd?
The best way to stand out from the crowd is to build a CV that displays clear leadership ability and an apparent interest in the field of informatics. One example to consider is to develop a quality improvement project during residency that focuses on improving the electronic health records system at your institution. 

Should I join a hospital committee?
Absolutely. Try to join a committee that is focused on informatics topics and allows you to make a meaningful contribution and/or allows for a leadership role. The Houstaff Patient Safety and Quality Improvement Committee is a good example.

Publications other than research
Writing case reports, blog posts, magazine articles, and so forth, is an excellent learning opportunity and a great way to get your name out into the informatics community. 

How many recommendations should I get? Who should write these recommendations?
It is generally recommended to obtain 3 letters of recommendation. One of these letters must be from your residency program or department director. The remaining recommendations should be from faculty who know you well, strongly support you, and can speak to your interest and skills in informatics. For example, physicians with whom you have worked on quality improvement projects, research projects, or on hospital committees may be a useful resource for these letters. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
You can absolutely still be competitive if you work as an attending before applying to fellowship. Some programs look forward to having applicants with prior independent clinical experience, as they could potentially provide a unique perspective. The key is to remain involved in informatics. You do not want the activities on your CV to stop when residency ends. Also, be prepared to explain during your fellowship interviews why you made the decision to practice before applying for fellowship. 

What if I am a DO applicant?
There are no barriers for DO applicants. 

What if I am an international applicant?
Please contact individual programs regarding whether they accept international applicants (some programs receive funding that prevents them from taking international applicants). In general, international applicants are usually required to be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). You also must have a visa (traditionally a J-1). 

APPLICATION PROCESS

How many applications should I submit?
You should apply to all programs you would seriously consider attending if offered a fellowship position. 

How do I pick the right program for me?
Pick a program that makes you happy in regards to career and personal life. Do not ignore your inner voice; if you feel uncomfortable, that program is not for you. Choose the program that believes in you and is supportive of your career goals. Finally, do not forget location. If you are unhappy when you go home after work, this sentiment will infiltrate your fellowship experience, and you won’t be nearly as happy or as productive as you otherwise would have been.

Common mistakes during the application process
Common mistakes include submitting an application past the deadline, submitting an incomplete application, choosing letter writers who are not 100% supportive of you, or having a CV that does not display an interest in informatics. 

Application deadlines
Applications traditionally open in July and positions are filled by January. Most programs are participating in the ERAS and will accept application through the ERAS portal only. Clinical Informatics fellowship programs are listed under a wide variety of primary specialty, however, most programs are accept applications from graduates of any ACGME-accredited residency specialty type. Applicants should contact each program regarding specific application timelines.

Tips for writing your personal statement
Your personal statement should not be a regurgitation of your CV but rather should show your personality and explain why you are interested in informatics. Is there a specific patient-technology interaction that first sparked your interest in the field? Perhaps your involvement in a hospital committee or maybe a mentor was pivotal in introducing you to the field? The best statements read as a story that engages the reader from the very first sentence. Consider ending your personal statement with your thoughts about your career goals after completing an informatics fellowship. 

Is this a match process?
Yes. However, applicants do not need to submit a rank-list. Instead, the directors of ACGME-accredited Clinical Informatics programs will pick a date and time, likely in mid-December, where they will simultaneously offer positions to their most desired candidate(s) by phone or email which will be active for one hour, after which time the offer will be automatically withdrawn. After an applicant declines a position (or accepts a position at another program or is automatically withdrawn due to expiration of their one hour offer window), fellowship programs with unfilled positions are then free to make offers to other applicants. 

What happens if I don’t obtain a fellowship position?
Not all programs will fill their positions during the match. If you decide to pursue Clinical Informatics late into the application season, or are interested in applying to programs which gained ACGME-accreditation or funding for a previously approved fellowship position later in the year, you may be able to individually reach out to programs that you are interested in to see if you can obtain a position outside of the match.

If you still do not obtain a fellowship, we recommend that you take a hard look at your application and interview process to identify weaknesses that you need to change. It may be worth gently asking the programs that did not offer you a position if they have any advice to help you to improve. More important, we recommend that you find a trusted physician (such as your EM residency program director) to look at your application with a critical eye to find the gaps. Spend the next year addressing these gaps and apply again. Worst-case scenario, it is possible to create a niche within the field of informatics as an attending physician without completing an ACGME fellowship.

Applicants who are able to complete a 24-month Master’s or PhD in Biomedical, Health Sciences, or Clinical Informatics; or are able to spend at least 10 hours per week doing Clinical Informatics work by the year 2022 may be eligible to become board certified in Clinical Informatics via the “Practice Pathway.” The National Library of Medicine also sponsors sixteen “University-based Biomedical Informatics and Data Science Research Training Programs” which may help physicians gain the skills they need to be successful informaticians. 

INTERVIEW PROCESS

How do I stand out from the crowd?
The best way to stand out from the crowd during an interview is simply by being yourself. Let your personality shine through. Come prepared to ask questions about the fellowship program. Make sure these are thoughtful questions that cannot be easily answered by looking at their website. Finally, know your application well and be prepared to answer anything from it. 

What types of questions are typically asked?

  • Why are you interested in informatics?
  • Why are you interested in informatics at our institution?
  • What are your 5- and 10-year career goals?
  • Tell me about “blank” activity that you list on your CV.
  • What are your strengths and weaknesses?

How many interviews should I go on?
Attend every interview that is offered to you by programs that you would seriously consider attending. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Englebardt SP, Nelson R. Health Care Informatics: An Interdisciplinary Approach. St. Louis, MO: Mosby; 2002.
  • Shortliffe EH, Cimino JJ. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. New York, NY: Springer; 2006.
  • Coiera E. Guide to Health Informatics. 3rd ed. Boca Raton, FL: CRC Press; 2015.
  • Strauss RW, Mayer TA. Strauss & Mayer’s Emergency Department Management. New York: McGraw-Hill Education, 2014.

Important skills to practice while in residency to prepare for fellowship
Practice your leadership, research, and negotiation skills. Above all else strive to be a fantastic physician first and foremost. Work on your understanding of electronic medical records, such as order sets, note templates, and decision support tools. Work on your understanding of the sociotechnical aspects of health care. Become knowledgeable on how to create and implement quality improvement projects. 

Tips on how to succeed as a fellow
The best fellows are the ones who are passionate and dedicated to their careers. Fellowship is a unique opportunity to learn about informatics under the guidance of many physician mentors. Take advantage of all that fellowship has to offer. Read every day, come into work early and stay late, and be amicable to everyone. Also, remember to stay balanced and take care of yourself and your family. 

CONCLUSION

Additional Resources

Journals

  • International Journal of Medical Informatics
  • Journal of American Medical Informatics Association (JAMIA)
  • ACI - Applied Clinical Informatics Journal

Blogs

Podcast

National organizations

American College of Emergency Physicians (ACEP)

American Medical Informatics Association (AMIA)

Emergency Medicine Residents’ Association (EMRA)

Healthcare Information and Management Systems Society (HIMSS)

Society for Academic Emergency Medicine (SAEM)

Conferences

  • AMIA iHealth clinical informatics annual conference
  • International conference on healthcare informatics
  • Medical Informatics World Conference
  • Healthcare Information and Management Systems Society (HIMSS)

How to find a mentor
A great way to find mentors is by reaching out the CMIO and physician informaticists within your institute. Alternatively, by joining the ACEP Emergency Medicine Informatics Section, you can connect with emergency physicians who share the same passion and could potentially serve as a mentor.