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Five Years of Clinical Board Certification for in the of America Christoph U. Lehmann1, Adi V. Gundlapalli2, Jeffrey J. Williamson3, Douglas B. Fridsma3, William R. Hersh4, Marie Krousel-Wood5,6, Christopher J. Ondrula6, Benson Munger6 1 Vanderbilt University, Nashville, TN, USA 2 University of Utah School of and VA Salt Lake City System, Salt Lake City, UT, USA 3 American Medical Informatics Association, Bethesda, MD, USA 4 Oregon Health & University, Portland, OR, USA 5 Tulane University School of Medicine and School and , New Orleans, LA, USA 6 American Board of Preventive Medicine, Chicago, IL, USA

passing of United States Medical Licensing Summary Introduction and Background Examinations, many states will grant a Objectives: To review the highlights of the new Clinical In the United States (US), the use of elec- a license to practice medicine. Informatics including its history, certification tronic health records (EHRs) has drastically Licensure indicates a minimum skill set and requirements, development of and performance on the increased in the last decade [1], resulting in knowledge and is not specialty-specific [5]. certification examination in the United States. a need for a specialized workforce in Clin- Successful post- training in Methods: We reviewed processes for the development of a ical Informatics. Recognizing physicians’ a specialty or subspecialty allows eligible subspecialty. Data from board certification examinations were expertise in Clinical Informatics and provid- physicians to apply for board certifica- collated and analyzed. We discussed eligibility requirements in ing them with certification fosters Clinical tion in their specialty or subspecialty and the as well as practice pathways. Informatics workforce capacity building to demonstrate the physician’s expertise in that Results: Lessons learned from the development of the Clinical meet the growing needs in the healthcare domain. Board certification is important as Informatics subspecialty, opportunities, challenges, and future industry. Although certification in Clinical it allows stakeholders including patients to directions for the field are discussed. Informatics is uncommon worldwide [2], identify physicians with a specific domain Conclusions: There remains a need for fellowship programs the American Board of Preventive Medicine expertise, it allows physicians to demonstrate and creation and maintenance of a professional home for the (ABPM) and the American Board of Pathol- exceptional expertise in a particular specialty subspecialty with the American Medical Informatics Association. ogy (ABPath) offered the first board certifi- and/or subspecialty of medical practice, and Ongoing to the currency of the core content is required cation examination in Clinical Informatics to benefits society by encouraging physicians to maintain an examination designed to test the key concepts eligible physicians in the US in 2013 [3]. The to seek, maintain, and demonstrate a higher within the field of Clinical Informatics. first cohort of successful examinees on the level of skills, knowledge, and expertise than inaugural examination were awarded ABPM is required of non-board certified physicians. Keywords board certification in Clinical Informatics Clinical Informatics, board certification, fellowship training, in 2014, thereby solidifying Clinical Infor- examination, American Board of Medical Specialties, physicians matics as an official subspecialty under the umbrella of the American Board of Medical Developing a Subspecialty Yearb Med Inform 2018: Specialties (ABMS) [4]. In order to be considered for new medical http://dx.doi.org/10.1055/s-0038-1641198 subspecialty status, certain requirements must be met. A new subspecialty needs a professional home in a specialty society, The Argument for Board Certification educational and training programs, and Board certification recognizes a physician’s sustained research. In the US, the American exceptional expertise in a particular specialty Medical Informatics Association (AMIA) and/or subspecialty of medical practice. In had been established as the home for infor- the US, board certification for physicians is maticians across the spectrum of clinical in- voluntary. After completing medical school, formatics. While nurses in the US established additional residency training, and successful a certification process in 1992 [6], the same

IMIA Yearbook of Medical Informatics 2018 Lehmann et al

was not true for physicians. In 2005, under the one of the authors (CUL), which developed for Clinical Informatics, included the caveat leadership of then AMIA CEO and President the initial item pool for the ABPM Clinical not to create an examination that would Don Detmer, AMIA members pursued a sub- Informatics certification examination. Prior assess all aspects of the domain nor to test a specialty assignment for physicians for Clin- to the administration of the examination in candidate’s knowledge of the latest-breaking ical Informatics with the ABMS and AMIA 2013, its development incorporated vetting medical news of the day but, instead, create was elected to membership in the Council of of the exam and other industry best practices an examination that is specifically designed Societies (CMSS) in 2006. to ensure reliability and validity and to as- to test the basic lasting concepts within the A new subspecialty further requires sure that the examination met or exceeded field of Clinical Informatics. With this charge commitment to advancing the field through industry standards. This process included a in , all committee members received peer-reviewed scholarly engagement and standard setting exercise, which established formal training in item writing and following research. Thus, opportunities for researchers the passing threshold for the examination. well-established best practices created ques- to present and disseminate their research in tions congruent with the Clinical Informatics the field are needed. AMIA - recognizing the core content. The result of this rigorous need for applied clinical informatics research process was an examination that included - established two tracks for its annual sym- Board Examination recall questions, interpretive questions, and posium: foundational and applied research, problem-solving questions, which reflect key with Clinical Informatics comprising a key Content concepts that are important and pertinent component in the applied track. The core content of the Clinical Informat- to the field of Clinical Informatics. The full While the Journal of the American Medi- ics subspecialty was created through an committee reviewed all questions in the item cal Informatics Association publishes papers AMIA initiative [13] and endorsed by the pool for accuracy and relevance. On an annual in the field of applied clinical informatics, ABPM [18]. The four major content areas basis, the committee augments the item bank the increasing adoption of EHRs [7], a are Fundamentals (10%), Clinical Decision by creating new relevant questions based on growing workforce [8], Making and Care Process Improvement the core content with the goal of maintaining the emergence of new roles including Chief (30%), Health Information Systems (40%), a robust item pool for future examinations. Clinical Informatics Officers [9], and in- and Leading and Managing Change (20%). After each examination, the committee creasing dialogue and discourse on the future The examination includes 200 question reviews the performance of the individual of the field [10] prompted the creation of the items. The examination lasts 4.5 hours items (i.e., validity, reliability, and objec- inaugural journal dedicated to Clinical Infor- starting when the examinee is seated at his/ tivity). Only those items performing within matics, Applied Clinical Informatics (ACI) her station. It is broken up into a 15-minute acceptable standards are retained for the pur- in 2009 [11]. ACI’s core editorial subject tutorial, four 60-minute blocks (50 items poses of scoring the examination. Items for matters include clinical information systems, each, for a total of 200), and 15 minutes of which statistical analysis confirms they were administrative and management systems, break time. Examinees may end any block too difficult, too easy, or did not differentiate eHealth systems, early at their discretion but cannot return to well between successful examinees and others development, deployment, and evaluation, previous examination blocks. Any remaining may be removed from consideration when socio-technical aspects of information block time is added to the allotted break time, determining passing scores for the examina- technology (IT) and health IT training [12]. which may be taken between blocks. tion. Additionally, the committee may select AMIA created a code of ethics for this new Consistent with industry best practices, items to be retired or sent for re-writing and field [13, 14] and in 2007 began the develop- ABPM via the Clinical Informatics sub- review to maintain the highest quality of the ment of the core content [15] that defines the board reviews core content items annually, item bank for future examinations. domain knowledge, key competencies, and develops new items, and periodically reviews skills in Clinical Informatics [16]. After the the core content outline to ensure relevance creation of the core content and the training and currency of concepts. Table 1 Attributes required in examination items [19] requirements [17] for Clinical Informatics, AMIA sought an administrative board spon- sor for an application to the ABMS [3]. Attribute Definition In 2009, the ABPM sponsored the appli- Exam Design Validity The question measures what it is designed cation for the Clinical Informatics Subspe- Certification examinations must be valid, to measure and covers the domain cialty to ABMS. In 2010, after a rigorous reliable, and objective as outlined in Table Reliability Applying the same test in the future will vetting process, ABMS approved Clinical 1. ABPM - based on the recommendation of generate similar scores (Repeatable with Informatics as a subspecialty available individuals from AMIA and the ABPath - con- the same results) to diplomates of all 24 ABMS Member vened a committee of 20 domain experts (17 Boards. Subsequently, ABPM organized a nominated by AMIA, three by ABPath), who Objectivity The performance on the test reflects how sub-board in Clinical Informatics including were charged with designing an examination. well the examinee understands and applies the skill (and not some outside influence) twenty experts in the field and chaired by The charge to this committee, the Sub-board

IMIA Yearbook of Medical Informatics 2018 Five Years of Clinical Informatics Board Certification for Physicians in the United States of America

Eligibility Practice Pathway Beyond insufficient Clinical Informat- ics experience, other applicants At the time of the preparation of this manu- do not meet eligibility criteria include To achieve general eligibility for the Clini- script, to be eligible for the board examina- cal Informatics certification, the physician insufficient time (lees than 36 months) tion under the Practice Pathway, the candi- must have graduated from a medical school in Clinical Informatics practice, less than date must fulfill the general eligibility criteria meeting ABPM standards, hold an active 25% effort during the 36 months, double and must demonstrate the completion of a board certification from an ABMS Member counting of training (e.g., the applicant two-year biomedical informatics master’s Board, hold an unrestricted license to prac- is requesting credit for time spent in program, two years fellowships sponsored tice medicine in every state or territory in another ACGME-accredited residency by the National Library of Medicine or the which the physician has a license to practice or fellowship program), and incomplete US Department of Veterans Affairs, or must medicine, and provide a letter of reference applications. Table 2 shows the number of demonstrate 36 months of substantial broad- from an ABMS-certified physician. Physi- applicants and their approval rate in 2017 based professional activity with significant cians, who are board certified in , for the Practice Pathway. Clinical Informatics responsibility (at least must apply for the Clinical Informatics certification through ABPath while appli- 25% effort) in the five years preceding the cants from all other ABMS Member Boards application. Candidates may receive partial seeking Clinical Informatics certification credit for fellowships of duration less than Exam Results apply through ABPM. The initial ABMS 24 months, AMIA 10x10 courses (virtual Each year, the Clinical Informatics sub- approval of Clinical Informatics allowed for courses utilizing curricular content from board examination is developed using a two pathways for certification: A Fellowship existing informatics training programs), or unique combination of questions from the Pathway and a Practice Pathway. masters-level courses in health informatics, item pool. While the questions in the exam- or ABPM-approved research and educational ination vary from year to year, the examina- activities in Clinical Informatics [18]. Clin- tion difficulty, by design, remains consistent Fellowship Pathway ical Informatics diplomates, who live and across examination cycles. Table 3 shows the In addition to the general criteria, eligi- work outside the US, mainly qualified via pass rates since the first examination. bility criteria for the Clinical Informatics the Practice Pathway. Fellowship Pathway include successful Consistent with ABMS-approved prac- completion of a 24-month full-time Ac- tices for new , the Practice creditation Council for Graduate Medical Pathway was initially approved for five Fellowships Education accredited Clinical Informatics years. This time interval was extended Beginning in 2023, only candidates trained fellowship [21]. for an additional five-year period after an in an ACGME-accredited fellowship pro- The Accreditation Council for Graduate ABPM petition to extend the timeline for the gram will be eligible for the Clinical Infor- (ACGME) accredited Practice Pathway was approved by ABMS. matics board examination. As of December the first fellowship programs (Stanford Therefore, applications for board certifica- 13, 2017, 24 ACGME-accredited Clinical University, University of Illinois at Chicago, tion in Clinical Informatics via the Practice Informatics fellowship programs were par- and Oregon Health & Science University) in Pathway will be accepted through the 2022 ticipating in the match for fellows in the US. 2014. The first applicants, who qualified via application cycle. Of interest to an international audience is the the Fellowship Pathway, were admitted to the Over the initial five years that the exam- fact that ACGME-International accredited examination in 2016. ination has been given, the percentage of programs exist [22], offering the opportunity The AMIA Community of Clinical In- applicants in the Practice Pathway, who did to establish ACGME-accredited programs formatics Program Directors (CCIPD) pro- not meet the eligibility criteria, increased internationally but keeping in mind that vides leadership and supports the continued annually. While the eligibility criteria for candidates must meet all current ABPM growth of ACGME accredited fellowships in the Practice Pathway and the committee requirements including, but not limited to Clinical Informatics [22]. members reviewing the applications have licensure and primary certification via an Table 2 shows the number of applications not changed since the first application cycle ABMS Member Board. and their approval rates in 2017 for the in 2013, the candidate pool appears to have Fellowship Pathway. Applicants applying changed over the five years the examination through the Fellowship Pathway have expe- has been administered with increasing num- Establishing and Accrediting a rienced higher approval rates compared to ber of candidates, who have not provided the Practice Pathway. Only one Fellowship sufficient evidence of Clinical Informatics Fellowship Pathway application was rejected because activity (e.g., clinical domain experts, who ACGME restricts the primary specialties that the applicant completed a program that collaborated with IT departments to generate may host a Clinical Informatics program to was not ACGME accredited at the time of health IT artifacts such as order sets, decision , Diagnostic , Emer- application. support, and documentation). gency Medicine, , Internal

IMIA Yearbook of Medical Informatics 2018 Lehmann et al

Table 2 2017 Application approval rates reduce length of stay [30] for patients and payers, may not be able to bill for the work Applications Applications Percent provided. In other clinical specialties, the Processed (N) Approved (N) Approved presence of a fellow increases the number of patients a physician can see, resulting Practice Pathway 290 222 77% in more billable events, which can justify Fellowship Pathway 19 18 95% the employment of a fellow. In Clinical In- formatics (and other specialties like Public Health and General Preventive Medicine), Table 3 Exam results 2013-2016. this incentive does not exist and as a result programs have to be innovative in how they fund their training program [31]. Examination (N) Certification (N) Pass Rate (%) 2013 488 445 91 2014 367 329 90 Roles of ABPM and AMIA 2015 400 320 80 AMIA is the professional home of the 2016 472 401 85 Clinical Informatics subspecialty in the US and provides education, networking (like 2017 249 192 77 CCIPD), and research opportunities. ABPM Total 1,976 1,687 85 is the administrative home of the Clinical Informatics board certification, while ABPM and ABPath are the sponsoring boards. Both organizations work closely to align their Medicine, and Genomics, Milestones activities. For example, AMIA provides Pathology, , or Preventive Medicine. educational activities for the maintenance ACGME develops Milestones for all of An eligible institution interested in creating of certification program. ABPM reviews and its training specialties including Clinical a Clinical Informatics fellowship needs to approves these activities. Informatics [24]. Milestones are points of complete an application with ACGME. The achievement along the path of a fellow’s application will be reviewed and if approved, education from novice to expert [25]. Twice the new program can recruit fellows. Usually Updating of the Core Content annually, program directors must compare after the first year, ACGME reviewers will eval- Few specialties or subspecialties have seen their fellows’ performance to the mile- uate the program on site. The specific program their domains change as rapidly in the last stones. The program’s Clinical Competency requirements can be found on the ACGME five year as Clinical Informatics. New Committee reviews the assessments and website under Preventive Medicine [23]. applications of informatics like precision reports them to ACGME. Figure 1 shows a Fellows require opportunities to acquire medicine [32], quantified self [33], and sample milestone. a comprehensive knowledge set. Most pro- wearable sensors [34], are starting to gain grams solve this need by subscribing to Clin- momentum, traction, and importance in the ical Informatics certification programs that application of Clinical Informatics to patient fellows can participate in remotely. Some Financial Challenges care and may have to be included in the core programs have on site master’s programs in With salary and benefits (including the cost content of the subspecialty in the future once Clinical Informatics that fellows complete of a master’s degree), the cost of Clinical they have reached mainstream status [15]. during the fellowship [Vanderbilt University Informatics fellowship training can range In this dynamic field of Clinical Infor- Clinical Informatics Fellowship Program. from $100,000 to $150,000 per fellow matics, ABPM is dedicated to the integrity Available online at https://www.vumc.org/ annually not including administrative and relevance of the examination and is dbmi/clinical-informatics-fellowship-pro- support. Unlike other clinical specialties therefore committed to ongoing evaluation gram. Last accessed 3/30/2018]. and subspecialties, Clinical Informatics of the core content. Therefore, when ad- Fellows must further have ample oppor- in the US does not have any billing codes vancements in the industry rise to the level tunity to gain practical experience. Many and does not generate revenue for the of becoming core to the practice, ABPM programs embed their fellows in health in- “practice of clinical informatics”. These will revise the core content as necessary to formation technology operations and create a are required to bill health care services to accommodate those advances and simul- rotation schedule (block diagram) that permits a payer. Unfortunately, a clinical informa- taneously update the Clinical Informatics fellows to observe and experience various tician, who performs services that reduce sub-board item bank. Consistent with this aspects of health information technology. cost [26, 27], improve safety [28, 29], goal, in 2017, ABPM and AMIA pledged

IMIA Yearbook of Medical Informatics 2018 Five Years of Clinical Informatics Board Certification for Physicians in the United States of America

Fig. 1 Sample milestone for Clinical Informatics

to partner on a comprehensive review of Additional opportunities include the pilot agreement from one or more accredited the core content for the Clinical Informat- development of new fellowships in Clin- fellowship programs. The ACGME has not ics subspecialty, which in turn informs the ical Informatics to foster the pipeline for addressed this issue directly but similar prob- annual update to the examination’s ques- physicians certified in Clinical Informatics lems exist for many newly developed sub- tion pool. Efforts such as the framework once the Practice Pathway expires in 2022. specialties and a solution may be applicable developed by AMIA for the Commission Working with ABMS to evaluate and appro- to a variety of other disciplines. The authors on Accreditation for Health Informatics priately design the program for maintenance are supportive of further collaboration with and Information Management Education of certification that meets stakeholder needs various stakeholders in an effort to develop (CAHIIM) will inform this collaboration will also be of importance. In this regard, innovative approaches to high quality train- [35]. ABPM and AMIA anticipate this ABMS is spearheading the Continuing ing and experiential that facilitate effort to begin in 2018 with an estimated Certification Visioning Initiative, which is and ensure attainment of core knowledge in duration of 24 to 36 months. designed to solicit meaningful input from the field while maintaining the integrity of all stakeholders and which will inform the the standards that form the foundation of this next generation of standards as they relate most important subspecialty. Future Opportunities to programs for maintenance of certification. As the Clinical Informatics field con- For ABPM, there are a number of opportuni- The demand on applicants by the sub- tinues to grow and as more organizations ties in the context of the Clinical Informatics specialty certification requirements to meet and offices implement EHRs, there will board certification. In 2017, administration eligibility criteria fosters high quality fel- be an increasing need for physicians with of the examination was transferred to the lowship training, primary board certification, demonstrated Clinical Informatics expertise National Board of Medical Examiners and licensure and will naturally entail that to address the challenges in implementation, (NBME). This transition has strengthened not every interested person will be able to clinical decision support, workflow, docu- the metrics and technical processes involved meet the eligibility criteria. However, with- mentation, and many other areas. Few data in the exam preparation process. out strict requirements and without the ter- exist on the career opportunities of newly AMIA is currently formalizing a leader- mination of the practice pathway in 2022, the certified Clinical Informaticians. Tracking ship structure within its Clinical Informat- incentives for obtaining fellowship training their career paths and their employment ics Community of Practice (CICOP) for would be undermined and fellowship pro- options will be an important task for AMIA. improved between AMIA grams would suffer, ultimately jeopardizing and ABPM. As the professional home the subspecialty itself. A potential solution of the Clinical Informatics subspecialty, to this dilemma would be a collaboration AMIA is developing a Fellow designation between ABPM and ACGME to propose an for Clinical Informatics diplomates, who alternative approach to fellowship training Conclusions make an ongoing commitment to lifelong that would recognize the challenges of In the US, Clinical Informatics became a learning practicing the medical subspecialty mid-career physicians and would ensure that board-certified subspecialty in 2013. Since of Clinical Informatics. Both efforts will relevant high quality experiences in Clinical its inception in 2013, the number of ABPM enable diplomates to surface key issues and Informatics are defined and made available board-certified Clinical Informatics diplo- communicate the value of the Clinical Infor- to interested clinicians. A viable proposal mates has risen and is currently over 1,400. matics subspecialty certification. would require a specific plan and ideally a Creating a new subspecialty including

IMIA Yearbook of Medical Informatics 2018 Lehmann et al

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IMIA Yearbook of Medical Informatics 2018