Imaging Informatics Fellowship Curriculum: Building Consensus on the Most Critical Topics and the Future of the Informatics Fellowship

Introduction

Guided by advancing technology and collaborative efforts from imaging experts, enterprise medical imaging is continually evolving [1]. Enterprise imaging encompasses the acquisition and management of interdisciplinary modality types (i.e., diagnostic and interventional radiology images, as well as visible light imaging such as digital pathology, endoscopy, ophthalmic photography, and other specialized applications). [2] Radiology and visible light imaging routinely fall under the governance of imaging informaticists. As the demand for medical images continues to increase, so does the need for efficient, safe workflow processes, and practices driven by imaging informatics [3]. Advanced training programs and fellowships in imaging informatics are a key contributor in addressing current areas of development, performing complex system integration, and shaping the future of the industry. These programs graduate the next generation of informatics leaders yearly. However, there is no current, widely accepted curriculum for imaging informatics fellowships, which may hinder graduates from operating at present-day demands and practices.

Historical Context of Imaging Informatics Education

The need for an imaging informatics fellowship became increasingly evident during the early period of the digital radiology revolution as early as 2002. On the basis of published literature, Bartholmai et al. initially discussed the value of a subspecialized radiologist informaticist as contemporary radiology practices demanded both efficient workflow and novel technology [4]. Subsequently, in 2004, Branstetter et al. explored the basis of a core curriculum at a time when informatics fellowship education content was ill-defined and widely different across programs [5]. The present radiology informatics prospectus stems from this early outline, which was adopted by the Society for Computer Applications in Radiology (SCAR, now known as the Society for Imaging Informatics in Medicine or SIIM) in 2004. As SCAR evolved into SIIM, a stated pillar of SIIM’s mission has been advancing imaging informatics across the medical enterprise through education. Nearly two decades later, there are now over 10 imaging informatics fellowships across the country, many of which are listed on the SIIM website [6]. Within that time, the discipline of imaging informatics has undergone significant changes with advents in artificial intelligence, new picture archiving and communication systems (PACS) standards, improvements in natural language processing (NLP), changing business analytics, and inclusion of other medical specialties, to name a few. This provides an opportunity to build upon previous work and identify some of the most critical components of a contemporary imaging informatics fellowship curriculum.

Providing important historical context for a fellowship curriculum is the compact, easily accessible, National Imaging Informatics Curriculum (NIIC), which has been created for radiology resident education as a week-long course sponsored by the Radiological Society of North America (RSNA) [7]. This course represents a tremendous amount of work to create both live and recorded lectures yearly over the course of one week that may be accessible to all residents, including those who will not be involved in an imaging informatics role later in their careers. Although this course is short-term rather than over the length of a dedicated informatics fellowship and dedicated to a general audience rather than aimed at fellow-specific education, it represents a key stepping stone for an Imaging Informatics Fellowship curriculum and serves as the basis for Imaging Informatics Fellowship sub-topics as defined in prior work [8].

Themes of Standardization in Curricular Reform

Speaking to the push for standardization across the gamut of medical specialties, medical education reform has been well-recognized as integral to ophthalmology, gastroenterology and minimally invasive surgery, and emergency care. Within ophthalmology, Lee et al. noted that the existing model, which refers to a traditional apprenticeship approach to teaching, lacked standardization, and as a result, programs and individuals were susceptible to wide variability in performance [9]. To address some of the challenges introduced by the modern healthcare environment, ophthalmology updated its curricula to a more comprehensive, structured, and competency-based model in 2013 [10]. Moreover, following analysis of a pilot study to assess feasibility of new educational content and accreditation criteria for advanced gastrointestinal and minimally invasive surgery fellows, Weis et al. concluded that a revised criteria would enhance fellow training [11]. Lastly, in their report advocating for the development of a standardized curriculum, Chahine et al. listed the need for sound and reproducible skillsets in the emergency care setting as a driving impetus for emergency radiology training standardization [12]. As evidenced by these examples, lack of uniformity within fields outside informatics has been an impediment to teaching, which has led to educational innovations and subsequently, implementation of standardized curricula. The positive changes achieved through the adoption of a revised curriculum in these instances support similar medical education reform in imaging informatics.

Essential Curricular Topics in a Dynamic Field and the Future of Imaging Informatics Education

Recent work characterized a broad universe of informatics topics identified by imaging informatic fellowship directors, which account for the current state of the field and its trajectory. Makeeva et al. found that all surveyed imaging informatics programs are incorporating new specifications and standards not found in previously available outlines (i.e., Fast Healthcare Interoperability Resources (FHIR) and Digital Imaging and Communications in Medicine web (DICOMweb)) [8]. In this investigation, our goal is to provide a consensus on topics considered essential while still providing a framework for informatics fellowship programs to customize their individual curricula. We surveyed informatics fellowship program directors across the country to determine the components and cutline for essential topics in a standardized curriculum, the consensus on essential versus supplementary knowledge, and the factors individual programs may use to determine if a newly developed topic (such as the development of FHIR since the publication of the 2004 SCAR curriculum) is an essential topic. We further identified typical program structural elements, such as available faculty and funding sources for the program. And finally, we sought fellowship director consensus on offering official graduate trainee certification to imaging informatics fellows.

Methods

This institutional review board-exempt study was performed in a Health Insurance Portability and Accountability Act-compliant manner.

As delineated in methods originally published by Vey et al., we surveyed directors of imaging informatics fellowships listed on the SIIM website with the focus of this work being only on fellowships focusing exclusively on imaging informatics offered to MD or DO applicants as opposed to radiology resident curricula, medical physicist’s training, or general clinical informatics training [13]. We directly contacted 10 programs via email and/or phone and were able to successfully arrange phone interviews with 6 (6/10, 60%) program directors. Only fellowships focusing exclusively on imaging informatics offered to MD or DO applicants, as opposed to biomedical or more general clinical informatics, were solicited. Surveys were administered using Google Docs (Google LLC, Mountain View, CA). Survey questions were related to four general categories: questions related to topic selection, questions related to inter-program collaboration, questions related to program structure, and questions related to imaging informatics fellow graduate certification. Question format consisted of a combination of 5-item Likert-type (5-LK) scale (1 = definitely not, 2 = probably not, 3 = neutral, 4 = probably, and 5 = definitely), multiple choice, and open-ended styles. Questions posed to program directors are presented in Table 1.

After we identified the 5-LK score above which a topic was agreed as essential, we mapped 29 broad categories and 114 sub-topics from Vey et al. and Makeeva et al.’s preceding manuscripts to one of the three numbered tiers based on 5-LK score and to a separate supplemental topics category related to the newly identified cutline [8, 13]. Essential topics were determined using this newly defined cutline, as detailed below. Sub-topics were based on materials from the National Imaging Informatics Curriculum (NIIC), a week-long course sponsored by SIIM and the Radiology Society of North America (RSNA) intended to provide a formal introduction to imaging informatics. The 114 sub-topics were adopted directly as written from the NIIC curriculum. For further clarification on topic groupings and definitions, please refer to the NIIC curriculum [7]. Expected level of proficiency within each sub-topic was not queried, given variations of proficiency expectation by different programs, which would represent a future area of investigation.

Results

Of the 10 program directors contacted, 6 (60%) responded. This response rate is comparable to similar studies performed [14–16]. All of the participating institutions recruited exclusively MD/DO trainees. Of the 6 program directors, there were 5 (83%) who agreed that there should be a single curriculum as opposed to two different syllabi (one of academic focus and one of clinical focus).

Among the interviewed imaging informatics directors, 50% (3/6) identified “3.5” as the mean 5-LK scale score cutoff to be used when selecting possible topics for inclusion into a core curriculum. Among the directors, 33% (2/6) favored a mean score of “3,” while 17% (1/6) opted for a mean 5-LK score of “4” (Fig. 1). In terms of factors which warrant consideration prior to making the determination that a subject should be accepted as a core sub-topic, 83% (5/6) of informatics program directors placed high importance on a sub-topic’s potential benefit to fellows’ future career in academics or in private practice. Among the program directors, 83% (5/6) also valued sub-topic presence in informatics literature and topic potential to foster leadership in a fellow’s future career, and 50% (3/6) placed significant standing on a sub-topic’s ability to help build common language with nonmedical informatics professionals. A sub-topic’s frequency of inclusion in standardized tests was voted on by 33% (2/6) of program directors as a factor which should be considered for core sub-topic determination. Meanwhile, potential benefit to entrepreneurial ventures, current interest in the topic among non-informatics professionals, and common component of future job were seen as the least important. These results are presented in Fig. 2.

Using a 5-LK scale, we mapped each of the 114 sub-topics into tiers (Table 2). Tier 1 (mean 5-LK scale score equal to 5) consisted of 10-sub-topics which received the maximal scores of 5 among all program directors: business management skills, DICOM, HL7, IHE, machine learning/artificial intelligence, natural language processing, PACS, standards, storage, and structured reporting. Tier 2 consisted of sub-topics which received broad consensus (a mean 5-LK scale score ≥ 4, but < 5). Tier 3 consisted of topics with a mean 5-LK score ≥ 3.5 and < 4.

Two programs requested that the following sub-topics also be considered for curriculum inclusion: alternate/virtual reality, Lean, Python, and Six Sigma. We surveyed imaging informatics program directors to rate the relative importance of each of these new sub-topics. Python received the highest mean score of 3.8/5 on the 5-LK scale, followed by Lean and Six Sigma, which both received mean scores of 3.2/5. Alternate and virtual reality received a less than favorable rating with a mean 5-LK scale score of 2.8/5.

One program director emphasized the importance of a project manager role, expressing, “Leadership and project management are pretty key unless they [imaging informatic fellows] are ng strictly imaging research. An informatics specialist is generally expected to help make technology decisions and lead project implementations.” Another program director called attention to product testing stating, “I can’t see informatics without some usability analysis.”

When asked about the importance of an imaging informatics certificate for graduating fellows, three programs (3/6, 50%) voted “3” on a 5-LK scale, the equivalent of a “neutral” stance. The remaining programs indicated a stronger desire to offer certificates to advancing trainees, with two programs (2/6, 33%) noting its “probable” importance and one program (1/6, 16%) denoting it “definitely” important.

In terms of the total amount of time fellows dedicate during their informatics training, the majority of programs (4/6, 66%) approximate 1,000 devoted hours throughout the course of the fellowship year when given the following choices: fewer than 300 h, between 300 and 400 h, 1,000 h, 2,000 h, and over 2,000 h. The other 2 programs (2/6, 33%) selected approximately 300–400 h or fewer than 300 h as sufficient. Further, one program director added, “We generally expect 2,000 h, but have had split/combined fellowships. A half year is probably possible to get expertise/training, but better to interleave with clinical duties so long projects can get done. Having no clinical duties/experience for a full year is not necessarily a good thing, but doing informatics work in a specialty area can be a bonus to the fellow and the clinical areas.”

All programs offered at most 1 imaging informatics fellowship spot per academic year. Institutional funding for said position originated from the radiology division in 50% of programs (3/6) and from the graduate medical education (GME) office in 33% (2/6) programs. One (16%) program reported not receiving funding. 100% of respondents reported their program having up to 5 imaging informatics faculty available to help educate fellows. Of note, one program director noted that albeit not considered faculty, their informatics staff (certified imaging informatic professionals (CIIP) and imaging informatics professionals (IIP)) play an important role in fellow education.

Discussion

As the field of radiology continues to undergo dramatic changes, a current and customizable curriculum is necessary. Consideration was made regarding the utility of two prospectuses, one for imaging informatics fellowship programs with an academic focus and another for those with a more clinical emphasis. Previous work has found disagreement between what should and should not be considered a core curriculum sub-topic [8]. One potential reason for these differences was posited to be that different programs have different objectives, such as those fellowship programs with an academic informatics as opposed to a clinical informatics focus, as the goals and objectives of a clinical informatics fellow and an academic informatics fellow may be inherently different. However, most of the current program directors, 83% (5/6), find instituting a single updated core curriculum appropriate.

Following review and analysis of surveys as well as communication exchanges with several imaging informatics fellowship directors, we propose an outline which highlights the most current and essential sub-topics and provides a blueprint/framework for tailoring topic selection to trainee interest and/or program resources. We further deliberate the value of an accompanying certification.

Limitations

The observational nature of our study renders it susceptible to biases such as nonresponse bias, which can sometimes lead to misinterpretation. To our knowledge, ten imaging informatics fellowships exist in the USA, four of which did not participate in this survey. While this is similar to comparable survey studies, the total response rate is small. Informal survey of radiology departments with clinical fellowships did not yield additional information on informal informatics fellowships that can be used to increase the response rate. Moreover, this specific cross-sectional type of investigation does not allow for temporal inferences. As the radiology industry evolves and fellowship programs undergo further developments, guidelines and technology would be expected to change and thus call for subsequent updates.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Brianna Vey, Valeria Makeeva, and Roger Gerard. The first draft of the manuscript was written by Roger Gerard, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Declarations