Health IT Workforce Training

Introduction
If the adoption of electronic medical records takes off in hospitals and ambulatory clinician's offices as the Obama administration hopes, there will be a huge demand for workers trained in the health care information technology field. Dr. Blumenthal, the National Coordinator for Health IT estimated in October that over 50,000 new jobs would be created. The task of educating all of these people, especially on the tight time schedule planned, will be enormous. The scope of new positions will include technicians, project management staff, consultants, engineers, trainers, and high-level administrators, among others.

Types of training needed
A broad spectrum of training programs will be required. Some technicians, analysts, and implementation specialists might be trained at community colleges in programs lasting as little as six months. Most positions will require at least a two year associate degree to provide students with adequate background and skills in health care and information technology to perform effectively in the workplace. More complex training at the bachelor's or graduate degree level will be needed for the mid- and high-level jobs. Schools will certainly be seeking students with prior experience in health care-related fields.

There will also be a tremendous need to train clinicians to effectively use electronic health records (EHRs.) About half of the graduates from clinical training programs in the last 10 years have had some exposure to electronic medical records. With the low adoption rate of EMRs/EHRs by practicing clinicians, very few of these providers have had experience using electronic records. The types of skills needed range from the simple manual skills of typing and keyboard use to more using more complicated applications such as templates for documentation, setting alerts at an appropriate level to balance clinician efficiency with patient safety considerations, and use of data mining to promote improved clinical care and population health. Clinician contribution to development of local systems is essential to successful implementation. Tasks include development of order sets, customization of clinical decision support systems, working effectively in groups, communication skills, conflict resolution, and general leadership. A number of clinicians will need to participate in executive information technology positions in hospitals and larger group practices.

Two types of training in my opinion have been under-utilized by many training programs. These are mentoring programs and apprenticeships. Graduating students often have few personal contacts in their future field of employment. This can make it difficult to find a satisfying job when recruiting is often word-of-mouth. Mentoring offers the opportunity for one to benefit from the wisdom and advice about professional development from experienced professionals who serve in an encouraging role. Apprenticeships offer a practical method of acquiring useful experience outside the classroom that can be listed on a résumé and that may be of benefit to the student when it comes time to search for a job.

Existing Programs
A large number of programs across the country offer training in health information technology. A search of the Internet will yield a variety of choices. Most of the shorter programs seem to be geared to coding and medical records management. Certificate programs for the study of medical informatics, electronic medical records, and health information exchanges are available. Many of these are designed around employed professionals and are offered online, after work or determined by a self-paced schedule. There are programs at the baccalaureate and masters degree level covering topics of general medical informatics, bioinformatics, and nursing informatics. A few programs offer graduate degrees at the PhD level in fields such as bioinformatics and genomics.

More and more programs are making the shift to online training. I recently noticed that my alma mater (Northwestern University School of Continuing Studies) will close its on-campus masters program in medical informatics shortly and will only offer the degree in the online format in the future. An internet search did not locate a significant number of programs comparable to those that the Department of Health and Human Services (HHS) is trying to develop through its grant programs discussed below.

HHS Funded Initiatives
Curriculum development: HHS will provide grants totaling $10 million to five institutions of higher learning to develop curricula for training in six job roles with twenty areas of expertise. The deliverables will used to provide a framework for dissemination to the community programs discussed below. (These programs were review in a prior post on December 14, 2009.)

Community college training programs: An additional $70 million will be awarded early next year to consortia of community colleges (five geographic areas and approximately 70 educational institutions) to provide support for the development of training programs in health information technology. Students will be expected to have prior experience in the health care industry. Training is expected to last no longer than six months. Many of the graduates are expected to provide support to the Federal Extension Centers that are targeted to begin operating across the country early next year.

Program for four year colleges: Last week, Dr. Blumenthal announced a $38 million grant program to be made available to four year colleges to develop more robust programs for job roles requiring longer and more specialized training. These training programs are to be rapidly planned and implemented.

Program Certification: I think that it will be essential for one or several well recognized certification organizations to develop certification pathways for health IT education programs. Students and employers will want to know that credentials are not being created in diploma mills. The schools should publish information about the certification status of their programs in a prominent location of their Web sites (homepage) so that there is transparency about this issue.

If programs are to be certified, perhaps students should be as well. This past week HHS announced a grant program to develop a series of competency tests to examine those who graduate from the non-degree programs that are to be developed next year. I think this is the beginning of a trend to test and certify those who design, build, and test critical clinical and administrative systems in the health care realm. It should be extended to the higher levels of training.

Challenges
Curriculum development. Training programs cannot achieve effectiveness without meaningful curricula. The curricula for training in health IT need to meet the diverse needs of students ranging from short term development in specialized areas to graduate degree education. Much of the workforce training needed immediately must address the short term goal of encouraging widespread adoption of electronic health records by clinicians, especially in small practices. For the long term, programs must focus on providing increased support for EHR usability, clinical decision support, and increased efficiency and safety for patients through the use of health IT in the U.S. health care system.

Teaching staff training and recruitment: One of the areas that federal grant programs have not addressed is training the trainers. Faculty development usually takes years to accomplish. There are powerful financial disincentives for skilled workers to enter the teaching ranks, especially considering today's weak economy. Development of online programs will require faculty members who are familiar with or can be trained rapidly to adapt to the technology that the online format requires. Programs will find it difficult to ramp up their health IT training without concerted efforts to develop the critical faculty needed on the front lines to teach and administer.

Funding new programs in a distressed economy. Students are finding it difficult to locate the financial resources to meet the demands of steadily rising tuition, book and supply costs, and other fees. Schools at all levels of the educational establishment have had their public funding and private endowments cut in the difficult economy of the last two years. Grant programs are a partial solution but they come with the limitation that funding is accorded on a limited time schedule, the reporting requirements can be onerous, and there are no guarantees that the grants will be renewed when their term expires.

Risks
Unknown adoption rates. Historically, the adoption of EHRs has been slow at both the provider and hospital level. The influence of ARRA on adoption rates is yet to be determined. For this reason, it is difficult to accurately predict the actual workforce training need.

Rapidly changing technology. Health IT technology is rapidly evolving. This is another factor that makes it difficult to predict training needs. Moreover, it adds a measure of uncertainty to curriculum development. The goal of providing students with skills they will need in the workforce is difficult to fulfill when there are so many unanswered questions. Also, there is a real risk that the newly trained students will not be available in the workforce in time for the early adopters of EHRs who need their services most. The maximum ARRA incentives are only available to those who are meaningful users of EHRs by 2011 and 2012.

Unknowns of the economy. The economy has already been mentioned as a confounding force in predicting manpower needs for health IT. If the economy rebounds, then the funds needed to complete the transition from paper to electronic medical records may become more readily available. If the economy continues to founder, then predictions of the future needs for the health IT workforce may prove to be over optimistic.

HIT Workforce Training

At the AHIMA meeting in San Francisco in early October, Dr. David Blumenthal, the national coordinator for health IT, announced government estimates that 50,000 new jobs would need to be created to support adoption of electronic medical records in the US. This was followed late last month when the Department of Health and Human Services announced $80 million in grants to train the health IT workforce.

The grant funds would be distributed in two pools. Institutions of higher learning with established health IT training programs will receive grants totaling $10 million for up to five Curriculum Development Centers to help create curricula designed for rapid training of students, using a standardized format. The assignment for grant applicants is to develop education programs in a collaborative fashion in which students with some previous background in health care will receive their health IT training over a six month span. The curriculum framework addresses 20 subject areas of expertise needed to perform health IT jobs. Grants are to be awarded in March 2010.

The second pool of funds consisting of $60 million will be distributed to about 70 community colleges in 5 national regions to establish the programs and perform the actual training. These training programs must ramp up rapidly to meet the two-year grant requirements. Training for six different roles is to be offered. These roles are:

Practice workflow and information management redesign specialists
Clinician/practitioner consultants
Implementation support specialists
Implementation managers
Technical/software support staff
Trainers

Trainees completing the programs are expected to have the skills necessary to support the Regional Extension Centers that are scheduled to kickoff early next year (first round grant winners should be announced in mid-January 2010. The HHS goal is to provide training to 10,500 students annually.

Analysis: HHS certainly has lofty goals. It would be great if ARRA helps create 51,000 new jobs in the Health IT arena. There are a lot of unknowns though. First, it will take several years to find out how much ARRA clinician incentives stimulate the adoption of EMRs/EHRs. So the actual demand for new trainees is not known. Second, it takes a lot of time and effort to get an education program started and running from scratch. I'm not sure the rapid development plans are adequately funded to meet the published requirements. Third, there is the issue of recruitment. Trained, experienced faculty will not simply materialize. There is a long lead time for faculty development and recruitment. Likewise, recruitment programs will need to be developed to attract qualified students. Furthermore, I question whether a six month training program will provide students with the necessary skills to meet the actual demands of the health IT industry. Just touching on all twenty of the required subject areas is going to take considerable time. Fourth, will an adequate supply of graduates from these programs be available in time to staff the Regional Extension Centers or other employers in time to help those clinicians interested in garnering the maximum ARRA incentives that will only be available on a very tight timeline? Finally, the recession has had a dramatically negative effect on budgets for higher education and associated student fees. The financial barriers will be difficult to overcome, even with the federal grant funds.

Look for future posts in which I will discuss training of the health IT workforce in more detail.

Future Role for HITSP?

There have been a lot of changes in government-led health information technology (HIT) initiatives since the Obama administration came to power in January. Much of the federal activity in HIT originates with the Office of the National Coordinator for Health IT (ONC.) Some of the changes have been discussed here previously, especially as they relate to EMR/EHR certification. There is another potential change on the horizon that I want to explore now.

The Healthcare Information Technology Standards Panel (HITSP) go its start in 2005 under a federal contract from ONC. HITSP is a public-private partnership with representation from a broad range of vendors, government bodies, and other organizations that contribute hundreds of volunteers to the standards harmonization process. The contract is due to expire at the end of January 2010, next month. Surprisingly, the federal government has not made public any plans it might have to extend the contract or substitute another organization to provide HITSP's services.

The standards harmonization process needed to enable interoperability of electronic medical records and health information exchange is not complete. In fact, the task is likely to be an ever-evolving one as standards development organizations (SDO's) continue to revise and formulate new health care related standards. HITSP advised ONC on standards to be selected for meaningful use for 2011, 2013, and 2015. These standards are still in flux. The government position on standards should become clearer by the end of December when an Interim Final Rule release by ONC is expected.

Unless government action is taken immediately, much of the effort invested in the creation of HITSP will be sacrificed. The organization was not designed to be self-sustaining. It was not easy to develop the governance structure, hire the full-time staff, and enlist the hundreds of volunteers that constitute the organization. The amount of effort that goes into developing a group like HITSP should not be underestimated. The government stands to loose the benefit of accumulated knowledge and experience of HITSP participants. It will not be easy to retrieve all the actors if they are lost during any significant hiatus in HITSP activities. As it stands today, HITSP will essentially shutter its doors on January 31, 2010.

Some may suggest that an alternative already is extant to replace HITSP. The HIT Standards Panel, a FACA committee, has been advising ONC on standards issues since it was established under the American Recovery and Reinvestment Act. Although there are dedicated experts on the panel, they are not capable of performing the work HITSP has been doing. I think it would be a real shame if HITSP is allowed to founder. It will also be a setback for the Obama administration's effort to encourage wide-spread adoption of interoperable electronic medical records for all Americans.