Dr. Alexander Towbin

Imaging informatics and the clinical informatics umbrella

July 18, 2018
by Sean Ruck, Contributing Editor
HCB News recently spoke with Dr. Alexander Towbin, associate professor in the department of radiology at University of Cincinnati as well as the associate chief of clinical operations and informatics and the Neil D. Johnson chair of radiology informatics.

Our conversation began with Towbin acknowledging that imaging informatics as a subspecialty is somewhat of a “forgotten” focus outside of radiology. “When I say it’s a forgotten specialty, I think it’s forgotten by the majority of people who are in clinical informatics,” he said. “But overall, imaging informatics is a very mature subspecialty, with representation from a healthy society (SIIM). We’ve been a digital specialty for over 20 years and we’ve been able to enforce standards on systems and automation over that time.”

While it has proven to be a progressive specialty, imaging informatics has faced challenges in getting others outside of radiology to understand how it’s part of clinical informatics, but at the same time, far enough removed that it requires some specific considerations. Towbin explained, “So if you were doing a clinical informatics fellowship or getting clinical informatics training, most programs would have very little training in imaging informatics. Healthcare informatics, especially clinical, focuses on the EMR – flow of data, its structure, how it’s pulled out and how it’s used to make discovery. Imaging informatics, in many ways, is very similar, but the methodology and standards used are a bit different.”

Some differences center on the images. In specialties where radiologic imaging is not obtained, end users enter information directly into a patient’s medical record. Radiologic imaging has traditionally used a different model in that the majority of data is created and stored outside of the EMR. Images are created on the modality and stored in the PACS and the imaging report is created in a voice dictation system. It is only the final imaging report that is sent to and stored in the EMR. The textual and patient demographic information is sent to and from the EMR using the HL7 standard. Images are stored and manipulated using the DICOM standard.

“Most clinical informaticists outside of radiology don’t have exposure to all of the systems that are used in the radiology department. They don’t have experience with DICOM, with image post-processing, or with managing the types of errors that can happen with images and what it takes to fix them,” said Towbin.

So this is a case where specialization holds high importance and although there is a unique skill set required to be highly efficient, the foundation clinical informatics provides is strong for those looking to move into imaging informatics. “Someone with informatics training in general, can pick up imaging informatics,” said Towbin. “There’s a lot of overlap, but there are some differences in training.”

Towbin detailed that, in his experience, an imaging informatics professional takes about a year to fully integrate into the team. “At about six months, they can start taking overnight calls, but they don’t really feel comfortable for the entire first year. They are learning a lot of systems and it takes time to understand the nuances of each one,” he said.

According to Towbin, clinical informatics boards for physicians don’t acknowledge a need for specialized imaging informatics training separate from the broader clinical informatics. The clinical informatics programs do not necessarily recognize that the two are different. “That makes it difficult, but not impossible, for radiologists to be board certified with informatics,” said Towbin. “In the short term it’s possible because there’s a grandfather clause allowing informaticists with experience to become board certified, but, that clause sunsets a few years from now. After that time, radiologists will have to complete a two-year fellowship to get the board certification. Many radiologists won’t complete the clinical informatics fellowship as it would add another two years to their training. This is in addition to five years of residency and one year needed for most clinical radiology fellowships.” If a radiologist were to complete a clinical informatics fellowship he or she would have to complete 7 or 8 years of post-graduate medical training. The two-year clinical fellowship is currently built for physicians who have completed an internal medicine, family medicine, or pediatrics training program. For these graduates, the total post-graduate training is five years.”

While Towbin stated that radiologist have much to learn from a clinical informatics fellowship, he stated that the added is significant and much of what is learned may not directly apply to a radiologist’s later work. Towbin believes that the major benefits of this type of fellowship training include a greater exposure to the EMR, a greater understanding of the challenges information systems solve and cause throughout the enterprise, and a broader understanding of clinical workflow outside of radiology. This type of experience can be invaluable for radiologists who have a desire to become a Chief Medical Informatics Officer or a Chief Informatics Officer. However, while this training can help a radiologist understand the challenges of the larger institution, it may not prepare him or her for the challenges of a radiology informatics practice.