OBJECTIVES: We report on findings from a meeting convened by the American College of Medical Informatics (ACMI) to characterize aspects of the patient experience that could be improved using informatics. MATERIALS AND METHODS: The American College of Medical Informatics fellows were invited to share their experiences as patients and suggest informatics approaches that may improve the patient experience. RESULTS: We identified 4 themes: (1) getting the right care, (2) data sharing and data interoperability, (3) guiding low-cost evaluations, and (4) predictive analytics. DISCUSSION: Despite widespread adoption of health IT, patient experiences remain far from optimal. CONCLUSION: The American College of Medical Informatics fellows identified informatics approaches, applications, and research areas that have the potential to improve patient experiences with health care systems.

OBJECTIVE: Accurately characterizing research trends is critical for identifying cutting-edge scientific breakthroughs in their infancy and informing strategic priorities. This research contributes a pipeline that utilizes generative AI technologies to develop research topic taxonomies from publication keywords and analyze keyword evolution within topics, methodological and domain trends, and topic co-occurrences. We demonstrated the pipeline by conducting a retrospective analysis of biomedical informatics research trends in the Journal of Biomedical Informatics (JBI). METHODS: We identified the JBI publications with keywords available on PubMed, spanning 2011-2025. We downloaded all the keywords and categorized them into methodological innovations and health domains, identified topics, assigned topic names, and constructed their hierarchies, all using large-language models (LLMs). We introduced an automated method for evaluating topics, leveraging MeSH terminology as the underlying knowledge base. RESULTS: Using 6,930 unique keywords from 2,427 publications, we derived 1,028 distinct topics related to methodological innovations, with each topic associated with medians of four keywords (Q1: 2, Q3: 13) and six publications (Q1: 2, Q3: 19). We identified 904 topics related to health domains, with each topic associated with three keywords (Q1: 1, Q3: 11) and four publications (Q1: 1, Q3: 15). Based on the topics, we analyzed the prominent research areas, trends in publication volume, evolution of keyword distributions within each topic, and patterns of co-occurring topics. Among the 2,379 eligible publications, 2,009 (84.4%) exhibited overlap between the keyword-derived MeSH terms and the MeSH terms assigned to the publication by the National Library of Medicine. CONCLUSION: This study presents a method that leverages modern generative AI technologies for retrospective analysis of a scientific field to identify emerging topics and to detect shifts in scholarly focus. Illustrated by data for JBI and correlated with historical background events and policy changes, our findings demonstrate the effectiveness and utility of the methods while providing a powerful lens to understand the evolution of biomedical informatics research priorities in JBI.

After 25 years of service to the American Medical Informatics Association (AMIA), Ms Karen Greenwood, the Executive Vice President and Chief Operating Officer, is leaving the organization. In this perspective, we reflect on her accomplishments and her effect on the organization and the field of informatics nationally and globally. We also express our appreciation and gratitude for Ms Greenwood's role at AMIA.

Over a 31-year span as Director of the US National Library of Medicine (NLM), Donald A.B. Lindberg, MD, and his extraordinary NLM colleagues fundamentally changed the field of biomedical and health informatics-with a resulting impact on biomedicine that is much broader than its influence on any single subfield. This article provides substance to bolster that claim. The review is based in part on the informatics section of a new book, "Transforming biomedical informatics and health information access: Don Lindberg and the US National Library of Medicine" (IOS Press, forthcoming 2021). After providing insights into selected aspects of the book's informatics-related contents, the authors discuss the broader context in which Dr. Lindberg and the NLM accomplished their transformative work.

OBJECTIVE: IBM(R) Watson for Oncology (WfO) is a clinical decision-support system (CDSS) that provides evidence-informed therapeutic options to cancer-treating clinicians. A panel of experienced oncologists compared CDSS treatment options to treatment decisions made by clinicians to characterize the quality of CDSS therapeutic options and decisions made in practice. METHODS: This study included patients treated between 1/2017 and 7/2018 for breast, colon, lung, and rectal cancers at Bumrungrad International Hospital (BIH), Thailand. Treatments selected by clinicians were paired with therapeutic options presented by the CDSS and coded to mask the origin of options presented. The panel rated the acceptability of each treatment in the pair by consensus, with acceptability defined as compliant with BIH's institutional practices. Descriptive statistics characterized the study population and treatment-decision evaluations by cancer type and stage. RESULTS: Nearly 60% (187) of 313 treatment pairs for breast, lung, colon, and rectal cancers were identical or equally acceptable, with 70% (219) of WfO therapeutic options identical to, or acceptable alternatives to, BIH therapy. In 30% of cases (94), 1 or both treatment options were rated as unacceptable. Of 32 cases where both WfO and BIH options were acceptable, WfO was preferred in 18 cases and BIH in 14 cases. Colorectal cancers exhibited the highest proportion of identical or equally acceptable treatments; stage IV cancers demonstrated the lowest. CONCLUSION: This study demonstrates that a system designed in the US to support, rather than replace, cancer-treating clinicians provides therapeutic options which are generally consistent with recommendations from oncologists outside the US.

A fundamental challenge in the field of clinical decision support is to determine what characteristics of systems make them effective in supporting particular types of clinical decisions. However, we lack such a theory of decision support itself and a model to describe clinical decisions and the systems to support them. This article outlines such a framework. We present a two-stream model of information flow within clinical decision-support systems (CDSSs): reasoning about the patient (the clinical stream), and reasoning about the user (the cognitive-behavioral stream). We propose that CDSS "effectiveness" be measured not only in terms of a system's impact on clinical care, but also in terms of how (and by whom) the system is used, its effect on work processes, and whether it facilitates appropriate decisions by clinicians and patients. Future research into which factors improve the effectiveness of decision support should not regard CDSSs as a single entity, but should instead differentiate systems based on their attributes, users, and the decision being supported.

This article offers suggested guidelines for graduate students who are embarking on informatics doctoral studies and anticipating the dissertation research and its documentation. Much of the guidance is pertinent for writing dissertations in other disciplines as well. The messages are largely directed at doctoral students, but some elements are also pertinent for master's students. All are relevant for faculty research advisors. The value of the dissertation is often underestimated. Too often it is seen as a hurdle to be overcome rather than an opportunity to gain insight into one's own research and to learn how to communicate effectively about it. Ideas that have been ill-formed often do not gel effectively until one tries to write about them. The main lesson is that the preparation of a carefully crafted, rigorous, logically evidence-based, and influential dissertation can be remarkably rewarding, both personally and professionally.

The AMIA biomedical informatics (BMI) core competencies have been designed to support and guide graduate education in BMI, the core scientific discipline underlying the breadth of the field's research, practice, and education. The core definition of BMI adopted by AMIA specifies that BMI is 'the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.' Application areas range from bioinformatics to clinical and public health informatics and span the spectrum from the molecular to population levels of health and biomedicine. The shared core informatics competencies of BMI draw on the practical experience of many specific informatics sub-disciplines. The AMIA BMI analysis highlights the central shared set of competencies that should guide curriculum design and that graduate students should be expected to master.

Tourism as well as international business travel creates health risks for individuals and populations both in host societies and home countries. One strategy to reduce health-related risks to travelers is to provide travelers and relevant caregivers timely, ongoing access to their own health information. Many websites offer health advice for travelers. For example, the WHO and US Department of State offer up-to-date health information about countries relevant to travel. However, little has been done to assure travelers that their medical information is available at the right place and time when the need might arise. Applications of Information and Communication Technology (ICT) utilizing mobile phones for health management are promising tools both for the delivery of healthcare services and the promotion of personal health. This paper describes the project developed by international informaticians under the umbrella of the International Medical Informatics Association. A template capable of becoming an international standard is proposed. This application is available free to anyone who is interested. Furthermore, its source code is made open.

AMIA has been the home for informatics professionals for 22 years, and has undergone a remarkable evolution during that time. Its autumn meeting continues to be a vibrant setting for the best in informatics science and practice, building on a tradition that started with SCAMC (the Symposium on Computer Applications in Medical Care) in 1977. Its journal, created in the early 1990s, is now arguably the preeminent journal in our discipline, combining cutting-edge science with important insights from the practice community. I have been honored to serve as AMIA's President during the past 3 of those 22 years and would like to take a moment to reflect on our recent accomplishments while acknowledging our ongoing challenges and exciting opportunities for the future. Among our recent accomplishments: We completed the roll-out of our rebranding effort with a new logo and a web site that has greatly increased functionality, a modern look, and is supporting ongoing efforts to enhance usability and the linkages to our membership database. Special attention to the membership site has made it intuitive and much easier to navigate for those who wish to join or renew membership. Although the new site was developed by an external public relations firm, we have smoothly assumed all responsibility for its maintenance and our web master has been enhancing the site rapidly based on both feedback and new requirements identified by staff and members. We have implemented and will soon broadly release our social/community web capability (Socious), which is tied to our member database and allows existing groups and committees to utilize modern methods for communication and document exchange. Socious also supports the spontaneous development of interest groups among members and we will be rolling out its full capabilities through a publicity effort in the next few months. Thanks to our relationship with the AMIA-TV production group (which produces videos for the Annual Symposium), we have enhanced our video offerings on our web site and in our e-News. There is also now an AMIA channel on YouTube, and we are retrieving from archive and releasing older video materials, such as the full collection of Collen Award DVDs and nursing informatics oral history tapes. Our proceedings archive is now available, with member and registrant access provided for all meeting proceedings going back more than a decade. We moved into new offices in Bethesda in late June, leaving behind the building in which AMIA had been located since its inception. The new space is superb and provides us with room to expand. Our corporate relations program has thrived, with a doubling in membership revenues due to both new members and increased levels of participation by renewing members. Equally important, we are building strong relationships with companies, with greater industry understanding of the value of their AMIA membership. We have learned to articulate better both the value of AMIA to our corporate members and what distinguishes us from other organizations in the field. Our corporate members are engaged and participating as they never have before and they are looking for collaborative opportunities. We have worked to improve our communication with members, both through the weekly e-News mailings (which are more professionally designed than in the past) and through these columns that have appeared at the end of each issue of J Am Med Inform Assoc since January 2011. We also introduced an Annual Symposium newsletter to help promote the annual event during the months leading up to the meeting. AMIA's Academic Forum has grown rapidly in membership, partly in response to the formalization of its rules of governance and the assumption of leadership roles by elected members. Forum members have assumed responsibility for planning their own annual meetings and have established task forces that are addressing important educational and certification/accreditation issues that are related to the clinical informatics subspecialty developments. We have totally revamped our corporate bylaws in response to evolving requirements of the organization and modified in response to the Board's strategic realignment efforts over the past 2 years. Our committee structure has accordingly been totally redesigned and there are now new and more meaningful opportunities for member involvement in the organization. With the help of a board-appointed task force, we rewrote, promulgated, and implemented new Conflict of Interest policies, placing pertinent information about individual potential conflicts in the members' section of our web site. The Ethics Committee has also updated our Ethics Guidelines and these were approved by the Board and will soon be published in J Am Med Inform Assoc. Our international programs have been redesigned and rationalized, driven in part by the recognition that our international efforts were fragmented and lacked a cohesive oversight process. The Global Health Informatics Partnership (GHIP, pronounced Gee-HIP) successfully completed its two grant-funded efforts (with support from the Bill and Melinda Gates Foundation and from the Rockefeller Foundation), having engaged international colleagues in planning for education and workforce development in resource-constrained environments. The Health Informatics Building Blocks (HIBBs) concept was embraced by OER Africa and the first several HIBBs are available for free access from http://www.oerafrica.org/hibbs/HIBBsHomePage/tabid/1568/Default.aspx. With the end of grant funding, GHIP has been integrated more logically with our other global informatics activities, including our relationship with the International Medical Informatics Association (IMIA). With new International Affairs Committee leadership in place and growing foreign recognition of AMIA's interest in and support for global programs and collaboration, the GHIP name will continue to be utilized as the AMIA label for its global programs and relationships. We successfully attracted a conference grant from the Robert Wood Johnson Foundation that supported our novel and well received Public Health Informatics 2011 meeting in Orlando. We have decided, however, to simplify our meeting offerings by eliminating the annual Spring Congress and to focus instead on our growing Joint Summits event in San Francisco each March and the thriving Annual Symposium every autumn. In 2012, however, we will still have a spring event due to our sponsorship of the Nursing Informatics 2012 (NI2012) meeting in Montreal, which is an important additional undertaking that has demonstrated our ability to host major international events, even when they are held outside the USA. The ‘Sharing Our Knowledge’ task force has made important recommendations that are already being carefully considered in the planning for AMIA 2012. Based in part on their preliminary presentation in Orlando in May, we implemented on short notice a few changes for AMIA 2011 in October, such as the satellite Workshop on Interactive Systems in Healthcare (WISH) with the Association for Computing Machinery (ACM) Special Interest Group on Computer-Human Interaction (SIGCHI) that was held on the Saturday before our conference. We have pursued closer collaborative ties with several other organizations this past year, believing that this is a key method for decreasing competition and serving our members more effectively. The ACM SIGCHI session is one example, as is our co-sponsorship of an IEEE informatics meeting held in San Jose in July. The ACM has become sufficiently interested in forging a close relationship with AMIA that we have established a joint liaison committee that is pursuing opportunities for collaboration. We expect recommendations from them in 2012. AMIA has also strengthened its relationship with the Council of Medical Specialty Societies (CMSS), assisting with scientific sessions for their members on health information technology (HIT) topics and studying and eventually supporting their Code of Ethics for Interaction with Companies. Similar ongoing discussions with the American Health Information Management Association (AHIMA) have resulted in a joint summary of the relationship between the two organizations and the role of informatics in their activities. That summary is complete and is posted on both the AMIA and AHIMA web sites. The clinical informatics subspecialty was approved by the American Board of Medical Specialties (ABMS) and AMIA forwarded the names of 12 self-nominated members as candidates to serve on the newly formed question committee that will be developing the certifying board examination. In addition, AMIA is aggressively pursuing the creation of board review course offerings, both online and face to face, and has established a special task force to guide staff in the creation, roll-out, and pricing of such programs. Our policy work continues to enhance our visibility and influence. Our formal submission of comments on proposed legislation, standards, and rule-making has continued apace, and we had another successful Hill Day in April. The invitational policy meeting in December was enthusiastically received by attendees, and we continue to have successfully published the policy papers based on prior year meetings. Our involvement with the National Quality Forum (NQF) continues to be vibrant, and AMIA was re-elected to membership in the National Priorities Partnership (which NQF runs under a contract from the Centers for Medicare and Medicaid Services (CMS)). We are frequently contacted by members of the press who seek our input on stories they are writing, and references to AMIA in news articles have reached an all-time high. In short, we are increasingly recognized as the home for informatics thought leaders and respected for our objectivity and focus on a safe and effective healthcare system. It should be clear that AMIA is healthy and effective, maintaining our core values while seeking new ways to deliver value to members and to the field. We face ongoing fiscal challenges, given the current economy, and are aware that we need to meet the needs of an increasingly diverse set of interests reflected in our membership. AMIA is especially grateful for the time, expertise, and commitment that its members have offered to our organization. AMIA could not flourish without the volunteerism that we have been fortunate to attract, and your efforts bring us excellence, credibility, and ongoing growth and influence. Our sincere thanks to all of you, and especially to those who are playing key leadership roles on our Board and on committees and task forces. Although I am moving on from my full-time AMIA position, I will remain engaged in both the field and the organization. As I pursue new interests, I plan to have ongoing opportunities to interact with the many AMIA members and leaders with whom I have had the privilege to serve these past 3 years. My personal thanks to you all. The purpose of the Messages from AMIA section is to provide a forum for AMIA to inform and involve its current and potential members about the goals and the directions of the association. These messages, which reflect the directions and opinions of AMIA leaders only, are intended to inspire members and readers to connect with the association on strategic objectives and activities. See also http://www.amia.org/presidents-page.

Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input-output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference's recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.

Darlene LeMay Pearson Vian, 78, of Palo Alto, California passed away on February 9, 2011. Ms Vian worked at the Stanford University Medical School for over 37 years. She was Secretary of the Faculty Senate for nearly 10 years. She was hired in 1980 by Ted Shortliffe to help establish the MS/PhD program in Biomedical Informatics and soon discovered that working with students was her true calling. As Student Services Administrator, she managed recruiting, admissions, degree programs, traineeships, social events at her home, the annual retreat at Asilomar Conference Grounds, and alumni relations, including an annual alumni banquet. Perhaps her greatest contribution came as an advisor to the students, helping them deal with issues of funding, coursework, thesis writing, deciding whether to leave school early, and personal problems. She was largely responsible for the esprit and positive experience that two generations of graduate students enjoyed. As an example of her unstinting devotion, she was still consulting to the program one week before her death. In recognition of her incredible work, Ms Vian was awarded the Stanford Graduate Service Award in 1999.

Since beginning my role as AMIA President and CEO in July 2009, I have been consistently impressed by the intensity and range of activities and programs within our organization. These events are lived and managed by AMIA staff members and by our volunteer leaders (including especially the Chair and members of our Board of Directors). They are aimed at meeting the needs of our members, the informatics and health information technology communities, and policy makers who need to understand informatics and its relationship to health, health care, and biomedical research. AMIA has many important and effective contributions, the most visible of which are through our multiple meetings and our journal, JAMIA. This issue of the journal introduces JAMIA's new editor, Lucila Ohno-Machado. Lucila has a number of strategies both to continue the quality of our two past editors and to enhance JAMIA for our continuously expanding readership. It has been my pleasure to know Lucila for a number of years, and I look forward to working with her and supporting her new JAMIA role. This issue of JAMIA is also introducing a new section of the journal for information from AMIA to our members and readers. In these columns, which will appear regularly in JAMIA, I or other association leaders will be offering messages about some aspect of the latest developments with which AMIA is involved. My hope is that a series of such summaries over the course of each year will convey to you the “big picture” of a remarkably dynamic and effective professional association, keeping its pulse on all the areas about which you—its members and subscribers—are passionate and in which you are deeply interested. For those of you who attended AMIA's 34th Annual Symposium in Washington, DC (November 2010), you saw first-hand the tangible success of some of the most intensive efforts that keep our staff busy for much of the second half of the calendar year. The Annual Symposium featured 102 scientific sessions and 364 posters. It attracted 2130 registrants, 70 exhibitors (accounting for another 300 attendees), and over 800 tutorial participants. Yet the numbers cannot fully capture the sense of excitement, engagement, and camaraderie that characterized the meeting, which seems to get better and more varied every year. If attendees express any frustration with the Symposium, it is that they find it difficult to choose among events that occur at the same time. To help to address this problem, you can catch the depth, breadth, and excitement of the Symposium online at http://symposium2010.amia.org/, where a number of video segments provide highlights of this richly stimulating and educational event. For the first time, the Symposium Proceedings are also available to attendees and AMIA members online rather than on the traditional CD-ROM; go to http://proceedings.amia.org/ to browse, download papers, or otherwise peruse the Symposium's rich content. Over the year that lies ahead, you will also find at this site an online archive of past proceedings, as we seek to use the electronic media to facilitate access to all of our scientific meetings and their research or educational content. As a glance at JAMIA's new cover will have indicated to you, AMIA enters the calendar year with a new face to the world! At the 2010 Symposium, AMIA revealed a fresh logo to replace the previous association symbol in use for the last two-plus decades. The new symbol reflects substantial research done within the AMIA community, with input from external sources as well. It also has been incorporated into the new look for the journal. We believe the new association logo better conveys AMIA's and JAMIA's future orientations, their cutting-edge focus on informatics, biomedicine and health, and their fluid and innovative approach to bringing positive change to healthcare, healthcare delivery, life sciences, and national health policy. A new tagline also has been adopted to describe AMIA and its membership more appropriately. Along with the logo, you'll often see: Informatics Professionals. Leading the Way. AMIA's leaders believe that this phrase is effectively descriptive of those in our field and hope you agree. As in the past, certain key products from the AMIA Board of Directors, or from task forces or other groups that they have appointed, will appear as special papers in JAMIA. In fact, there are two such papers in the current issue, one dealing with AMIA's policy meeting from 2009, and the other reporting on an important study by an AMIA task force that examined issues related to contracting between information system vendors and their hospital or health system clients. There is a lot of new thinking going on around all parts of AMIA these days and you will likely notice new language describing the association as “the center of action,” and “the voice of the profession”. We are reaching out to many new audiences and communities, often using a more casual, vernacular style to make AMIA accessible and understandable to anyone interested in supporting us, joining us, reporting about us, or just observing us. Future columns in this series will cover pressing topics about which I often feel that our members, and the external community, are not being optimally informed. AMIA's policy work, for example, is having a major influence in the health policy community, but surveys suggest that our members, and readers of JAMIA, are not always aware of those activities or the growing reputation that AMIA has developed as an objective source of education and policy advice. Similarly, we are reaching out to constituencies that have not always felt at home in AMIA—but which are crucial to our growth, quality, and effectiveness. These include the corporate world, in which many graduates of informatics degree programs are making major contributions as researchers, managers, entrepreneurs, consultants, or executives. Our new Vice President of Corporate Relations, Jonathan Grau, is working diligently to build relationships with industry and to bring more corporate partners to our meetings and our membership. Similarly, we are eager to enhance the organization's role in supporting informatics practitioners, and especially those in healthcare systems, such as CMIOs and CNIOs. Our new bootcamp series, successfully offered during the last two years, is testimony to our commitment to this growing community. The changes and activities I have described are not simply cosmetic. They indicate a new awareness and commitment to make AMIA an even more influential and effective force for the field of informatics, its practical applications, and its importance to the health of populations both domestically and globally. One major change, which will affect all our members as well, is the unveiling of a totally new web site, which will occur over the next few months. The developing new http://www.amia.org was previewed in the AMIA booth at the November symposium, and was met with enthusiastic reviews. The new AMIA web site is more modern and dynamic with new navigation and content and we believe it will provide a more rewarding online experience. One of my goals is to assure that AMIA members are consistently proud of their organization, are excited to be a part of it, and will want to maintain their membership, their readership of JAMIA, and their participation at our various scientific and educational offerings throughout their careers. AMIA is growing, even at a time of economic downturn in our society, and resources do not always match our aspirations, thereby requiring prudent prioritization and careful budgeting. But we look to our members for regular feedback about what is working and what can be improved; please send us your comments or suggestions at any time. The purpose of the Messages from AMIA section is for AMIA to communicate and involve its current and potential members in AMIA. The messages on these pages reflect the goals and direction of AMIA's board of directors and leaders only. These pages are designed to inspire members and readers to connect with the association on strategic objectives and activities. We hope you will find them a useful tool for keeping connected to AMIA leadership. We welcome your thoughts and feedback.

Although informatics is often viewed externally as a new discipline, the field has a rich history that dates back at least to the 1960s, with a well-known seminal paper appearing even earlier.1 AMIA itself was created in the late 1980s when three separate informatics organizations, with overlapping interests, saw the value in combining their missions and activities in a single, larger, and more cohesive organization. Those three nonprofit corporate entities (SCAMC: the Symposium on Computer Applications in Medical Care; AAMSI: the American Association for Medical Systems and Informatics; and ACMI: the American College of Medical Informatics) dissolved their own charters and pooled resources to form a new organization that would incorporate the activities of all three. SCAMC became the AMIA Annual Symposium, which we hold every fall, AAMSI became the membership organization, and ACMI was re-created within AMIA as its College of elected Fellows. All three activities continue to thrive to this day, as does our annual spring meeting, which owes its roots to the annual AAMSI meeting, which was held at that time of year. The world of informatics has changed dramatically since AMIA was formed, and the association has accordingly evolved as well. That evolution requires introspection and decisions—ones that need to reflect our roots and to reaffirm the critical importance of disciplines such as computer science that gave rise to informatics, as well as to embrace change when appropriate. AMIA's roots are firmly planted in academia, corporate research, hospitals, and other clinical practice settings—plus the government agencies (notably the NLM and predecessors to AHRQ) that supported early research in our field. “Hot areas” of today, such as public health informatics and bioinformatics, had not yet taken shape and those labels did not yet exist (although there were, of course, early applications and research projects in both areas). In academia, informatics researchers came from engineering schools and computer science departments, and gradually from medical or nursing schools and the nascent informatics units that began to emerge at a few schools. In the early years of SCAMC, which held its first meeting in 1977, talks were often technically oriented, since the underlying science was still young and systems for implementation were immature and largely offered by an emerging but small industry. For a few years, in fact, the SCAMC Proceedings (a large two-volume collection of presented papers) was published by a large engineering professional society, the IEEE.i Computer scientists had much to offer to the young and rapidly evolving field, and many of today's senior academic informatics leaders entered the community from a home in computer science, guided by a desire to work on socially important and computationally challenging problems. Graduate students in biomedical informatics continue to learn a great deal of computer science, as is reflected in the core competencies that our Academic Forum has recently defined.ii Although informatics clearly has other core component sciences with which our students need to be familiar (decision science, information science, cognitive science, management science, organizational theory, and the like), computer science is broadly assumed to be a fundamental part of the discipline. Thus, AMIA continues to embrace the role of computer science and needs to serve a computer science community that increasingly finds motivation and challenges in the world of biomedicine and health.2 With the growing heterogeneity of the AMIA membership, and the audience at the Annual Symposium each year, it is an increasing challenge for one meeting to serve the needs of all segments of the organization. It is accordingly not surprising that AMIA's leaders have heard occasional complaints from groups that once felt at home at our meetings but now begin to find it difficult to remain engaged. We first heard such rumblings from some members of the computer science community in late 2009, and I immediately took the concern seriously and wanted to rectify them. My own background is in computer science as well as medicine, and I am fully aware of the key role that computer science has played in the evolution and progress of our field. AMIA accordingly undertook an effort to understand the basis for the concerns that had been expressed and made several changes in 2010 that will continue into 2011 and beyond. One set of changes has to do with the selection of papers for presentation at our Annual Symposium. We revised the descriptors of paper categories to include more emphasis on methodology, updated and thinned our reviewer database to assure more accurate matching of papers to reviewers, and made it clear that reviewers were expected to give substantive critiques of a paper, especially if they were recommending rejection. We also had a well-attended panel discussion at the 2010 Symposium on the subject of computer science's relationship to informatics and to AMIA. In addition, the 2011 Symposium's Program Committee has greater involvement of computer scientists, especially for the Foundations Track. Limits on the length of papers have been relaxed in order to make it easier for authors to write more substantive papers that lay out their methods in more detail. We are also considering further changes for 2012 and beyond, based on this year's experience. We believe the changes will be positive for all authors—not just for those from the computer science community. At the same time AMIA has come to recognize that certain communities within our membership are eager to have more narrowly focused meetings sponsored by the organization. The Joint Summits on Translational Science, held in San Francisco each March, have provided a much needed event for focused involvement by members from the translational bioinformatics and clinical research informatics communities. Similarly, this year's spring meeting in Orlando has been designed to focus on the needs of informaticians and practitioners working in the area of public health. We will continue to explore other areas in which focused meetings may be feasible, either created by AMIA alone or in partnership with other organizations that have overlapping interests in a narrowly defined area of informatics research and practice. Such discussions, for example, are underway with organizations that serve the computer science community, although no definite plans can be reported at this time. Like informatics, computer science is far from static. There was a time when computer science faculty members were criticized if they worked on biomedical problems or their work was viewed as “too applied”. Today we are seeing gradual change in those attitudes, as many departments have recruited bioinformatics faculty or clinical informaticians, and the core scope and requirements for computer science are being scrutinized from within.3 My message, then, is that AMIA recognizes that it needs to evolve its offerings and its ways of serving members, especially in light of the broadening of the field and the increasing diversity among our membership. Our diversity is healthy, as informatics has daily influence on the care of patients and the pursuit of biological research, and as we seek to embrace and engage basic researchers, applied researchers, and practitioners, regardless of whether they work in academia, corporations, health systems, or government. As always, we seek your feedback and advice as AMIA and its Board of Directors guide the organization into the years ahead. The purpose of the Messages from AMIA section is for AMIA to communicate and involve its current and potential members in AMIA. The messages on these pages reflect the goals and direction of AMIA's board of directors and leaders only. These pages are designed to inspire members and readers to connect with the association on strategic objectives and activities. We hope you will find them a useful tool for keeping connected to AMIA leadership. We welcome your thoughts and feedback.

In my inaugural column in January 2011, I described the recent efforts by AMIA to assess its current and future roles, and the ways in which we are perceived by our members and by external groups. Insights from formal and informal surveys have led to a number of changes, including our new logo and branding, our new website, and our explicit efforts to broaden our membership within the informatics and health-information-technology communities. One element in the surveys was particularly surprising to us, however. Our members expressed a desire for AMIA to be more involved in public policy work and to represent the field visibly and effectively as legislation and regulations are developed and promulgated. Yet this is an area in which AMIA has evolved dramatically in recent years, and our role and effectiveness in Washington, DC and with major policy groups are well known to the organization's leadership and to our colleagues in other societies. Since it appears that some of our members are unaware of the significant work that AMIA does in the policy arena, I would like to devote this issue's column to providing a brief update on this topic. From its inception more than two decades ago, AMIA has had a public policy committee, and its volunteer members did what they could to represent the field and its interests and to inform other members about evolving policy issues. Fortunately, with the 2004 recruitment of Dr Don Detmer to his role as President and CEO of the association, we had full-time expertise in health and health-information-technology (HIT) policy on the AMIA staff. Don brought significant experience to his role, as well as a passion for policy matters, and he very quickly began to transform AMIA's activities and influence, both with other policy groups and with our representatives in Congress.1 Within a few years, he had recruited to AMIA an experienced policy expert, Meryl Bloomrosen, who took the lead on many of our policy-related activities and, with her current staff of two additional people, serves as AMIA's Vice President for Policy and Government Relations. To complement our in-house expertise, AMIA also works with Doug Peddicord, PhD, President of the Washington Health Strategies Group, who, with his own team based near Capitol Hill, has since the late 1990s played a key role in representing to Congress AMIA's interests, and the interests of the informatics community, and in working with us to analyze pending legislation and proposed rule-making. Many of our members have had opportunities to meet with Meryl and Doug as we have increased the number of policy-related offerings at the AMIA Annual Symposium every autumn. With Don Detmer's departure and the initiation of my own role at AMIA, I too have become actively engaged in policy work. Our most recent effort was another successful Hill Day in Washington (our eighth annual event), a remarkable opportunity for AMIA members and leaders to work together in bringing key messages about informatics and HIT issues to our Representatives, Senators, their staff members, and key committees on the Hill. Those members who have participated can attest to the combination of exhaustion and exhilaration that they feel at the end of a day talking with people who make the laws and regulations that drive our public health and healthcare systems. Walking the halls of Congress, and talking with the people who work there, is both a lesson in civics and an opportunity to appreciate the willingness of lawmakers to open their doors to hear from, and be informed by, constituents. And the effort is worth it! We leave materials and business cards, and AMIA often hears back from those we visit with questions about pending legislation or other matters about which they need information from an unbiased and authoritative source. I have personally been told by our contacts on the Hill that they appreciate AMIA's visits because we clearly are advocating for the interests of patients, citizens, and the quality of our healthcare system. For 5 years, AMIA has sponsored an annual invitational policy meeting in Washington, DC. These events have typically brought together approximately 100 AMIA members, invited guests, and representatives from Federal agencies. Focusing on a single theme for each meeting, the autumn meetings have been well received and have produced written reports that have in turn been published and have influenced policy discussions. For example, a paper discussing the 2009 policy meeting and recommendations was published recently in JAMIA.2 Current key issues of our policy focus include ensuring the availability of a trained informatics workforce, protecting and encouraging funding for core biomedical and health informatics research and training programs and services, and guiding sound implementation of HIT. The passage of the ARRA and HITECH acts has placed AMIA in the vortex of Federal attention on HIT and the dissemination of EHRs into practices and health systems. AMIA is frequently invited to testify before Federal policy committees or to comment on pending legislation or proposed rules, and we turn to our Board, our Public Policy Committee, and policy liaisons with our working groups to assure that our responses are well informed and reflect a consensus. Similarly, the Office of the National Coordinator for HIT has turned to a large number of AMIA members who serve on the HIT Policy and Standards Committees. Our members are similarly engaged in, or testify before, other Federal and private advisory groups, such as the National Committee on Vital and Health Statistics, study committees at the National Academies, the National Quality Forum, the National Committee on Quality Assurance, and many others. AMIA recognizes that involvement in public policy, government relations, and advocacy campaigns at the national level are essential to the success of AMIA's overall mission (to transform healthcare through trusted science, education, and practice in biomedical and health informatics) and in support of our strategic plan.3 Those of you who have not had a chance to learn about AMIA's policy activities and positions should explore the policy pages on our website, where all recent and past comments and letters are posted. You may be surprised to discover the large number of requests to which we respond—often several every month. It is a reflection on the current era that we typically cannot respond to every invitation; our resources will not permit us to weigh in every time. We accordingly choose to focus on topics where our expertise is unique, and where we likely have a special perspective that might not otherwise be reflected in comments submitted by others. We invite members to follow our policy activities on the website, to get involved when you see a call for comments on an issue in which you have a particular interest, and to provide us with your perspectives so that we can try to be sure that our responses are balanced and well informed. AMIA's comments are meant to be those of its members, not just the leadership, so we look to you for guidance on the important topics that affect informatics, the HIT arena, and, of course, the health and healthcare of the nation. The purpose of the Messages from AMIA section is for AMIA to communicate and involve its current and potential members in AMIA. The messages on these pages reflect the goals and direction of AMIA's board of directors and leaders only. These pages are designed to inspire members and readers to connect with the association on strategic objectives and activities. We hope you will find them a useful tool for keeping connected to AMIA leadership. We welcome your thoughts and feedback. None. Internally peer reviewed.

As I discussed in a recent president's column,1 the roots of AMIA's founding and early identity were largely academic, with an emphasis on informatics and computer science research, both basic and applied. Yet, with the passage of time, yesterday's research has evolved into standard approaches and tools. Today's clinical computing products often reflect research that was carried out in academia or other investigational settings 10, 20, or 30 years ago. Similarly, today's research and development work will be reflected in products a decade or so in the future. This observation emphasizes the ongoing importance of basic and applied research, to fill the pipeline with the ideas and methods that will define the systems of tomorrow. With the evolution of the field, AMIA has necessarily evolved as well, and now embraces a much more diverse membership and, accordingly, different member expectations.2 There is a greater emphasis on applied research and practice, health information technology policy, broad workforce development, and the increasingly successful and mature world of commercial health information technology. In this column I would like to focus on AMIA's increasing interactions with the corporate world and our major efforts to identify and nurture synergies at that interface. AMIA, its members, and the biomedical informatics community have much to contribute to industry and much to gain from healthy relationships with the companies that work in diverse areas such as electronic health records, computerized provider order entry, mobile health, translational bioinformatics, consumer health, public health, and clinical research. First, many of our student members complete their informatics training and move into industry for their careers (eg, in corporate R&D, marketing, consulting, management, and the creation of startups). With training grounded in the AMIA community, often at institutions that are members of our Academic Forum, these graduates appreciate the intellectual environment that AMIA offers through its meetings and publications and want to stay involved. We are working hard to ensure that our student members who choose careers in industry will still see value in maintaining their association with AMIA. We also need them on committees and in leadership roles to provide balance in the organization. The AMIA community also publishes papers, gives talks, and promotes policies that affect industry and in some cases drive product development and the incorporation of research results into products. Thus the corporate community looks to the informatics field for ideas, methods, and in some cases licensable software, that positively affect the evolution and design of commercial products. In addition, those in academia often derive satisfaction from seeing their ideas and research products reflected in real world systems that positively influence patients and the quality of healthcare. Our individual and corporate members from industry also have much to contribute to those AMIA members who derive much of the motivation for their work from real world examples and problems identified on the ‘front lines’ by their corporate colleagues. These synergies benefit AMIA members of all types and help to explain why the organization has sought to nurture stronger ties with industry. Members from industry also offer key insights that complement those of our members from academia, industry, government, and healthcare. For example, three of our members from industry played pivotal roles on our vendor contracting task force that produced an influential report that was published in JAMIA earlier this year.3 AMIA's leadership decided to create a new staff position in 2010, seeking to respond to this need for improved and synergistic ties with industry as well as the growth of our membership by individuals from within the ranks of commercial companies. Many of you will have already met Jonathan Grau, our Vice President for Corporate Relations and Development, who joined us in May 2010 and has built a robust and growing corporate relations program in the intervening months. He joined us at a time when there were already new activities underway to strengthen our corporate ties, including the introduction of an ‘Industry Day’ on the Monday of our Annual Symposium (including specially designed sessions in a single track), beginning in 2009. We had also created an Industry Advisory Council (IAC), initially chaired by two of our active members from industry, Steve Labkoff and Dan Foltz. Building on this momentum, Jonathan helped us to create an even larger and more successful Industry Day at the 2010 meeting, to be reprised again in 2011. The sessions have been well attended, especially by students and recent graduates who are seeking information about career options in industry. Equally important, Jonathan has built a redesigned corporate membership program (see AMIA's new web site for details) that clarifies the value proposition for companies that are considering joining AMIA. Ours is a professional society, not a trade organization, and we have a vibrant but modest exhibit program at our meetings. The emphasis of our industrial relationships has been on intellectual exchange, policy discussions, and interactions with both our students and our member thought leaders. The new program has several categories of involvement by companies, varying with size, types of products, and the organization's major goals in building a relationship with AMIA. Thus, although we have generic descriptions of the various types of relationships available, the final design of a corporate membership is individualized to the company's specific needs and concerns. Furthermore, many organizations have appreciated the flexibility that a single annual membership fee can deliver. Custom benefit packages can include event sponsorship and advertising and help cut down on repeated requests for payments during the course of the year. Jonathan Grau has become the point person for developing and maintaining these corporate ties and is now a recognized and respected spokesperson for AMIA and its membership. He has successfully increased the number of corporate members, thereby enhancing the membership in IAC and the strength and quality of its meetings and growing programs. It is important to emphasize that AMIA's new programs to enhance our corporate relations are meant to broaden our scope and interactions while we maintain our traditional emphasis on informatics science and the evolution of the scholarly discipline. It is a sign of the growth and health of our field that our mission has broadened to include applications, informatics practice, and the industry that has developed to take biomedical and health informatics to the marketplace, with opportunities for our ongoing input in that process. The purpose of the Messages from AMIA section is for AMIA to communicate and involve its current and potential members in AMIA. The messages on these pages reflect the goals and direction of AMIA's board of directors and leaders only. These pages are designed to inspire members and readers to connect with the association on strategic objectives and activities. We hope you will find them a useful tool for keeping connected to AMIA leadership. We welcome your thoughts and feedback. None. Internally peer reviewed.

Shortly after Don Detmer joined AMIA as its first full-time professional president and CEO, he became aware of the growing demand among clinical informaticians for a process by which they could be credentialed to show their competence and accomplishments in the field. Such credentialing would require consensus on the design and content of training programs for clinical informaticians, and AMIA seemed to be especially well positioned to develop the materials necessary to promote the process. In early 2007, with support from the Robert Wood Johnson Foundation, AMIA embarked on an 18-month process to define the field of clinical informatics, its core competencies, and the rationale for recognizing a formal subspecialty in the area.1 Several AMIA members were invited to serve on the study groups that produced key documents that were ultimately approved by the AMIA board of directors and published in J Am Med Inform Assoc. One dealt with the core competencies in the field, helping to define the knowledge base that needs to be reflected in any curriculum for training individuals in the burgeoning discipline.2 The second focused on recommendations for program requirements in the creation and promulgation of fellowship opportunities for subspecialty training.3 In parallel with these activities, Dr Detmer was pursuing the engagement of AMIA with the Council of Medical Subspecialty Societies (CMSS), which is an umbrella organization for all the physicians' specialty societies, representing their shared interests and collaboration. Not only was Don successful in representing the case for AMIA's election as a full member in CMSS, but he was elected to their board and served as CMSS treasurer for several years. The strong support for clinical informatics among the established medical professional societies led Don to begin discussions with some of the associated clinical boards about their interest in proposing a formal subspecialty certification examination in clinical informatics.i Although there was broad support from the boards (which together are coordinated by the American Board of Medical Specialties, ABMS), it was the American Board of Preventive Medicine (ABPM) that expressed particular interest in serving as the sponsoring board for a clinical informatics subspecialty certification.4 They asked AMIA to work with them on preparing the data and background materials that would serve as the basis for a formal proposal to ABMS, which would need to approve the creation of a new subspecialty. Shortly after I joined AMIA in 2009, I made a presentation to the ABPM on the rationale for a formal subspecialty in clinical informatics and we were delighted when members of that board voted to sponsor the proposal to ABMS. The previously mentioned J Am Med Inform Assoc articles1–3 were particularly helpful in the process, as they demonstrated the nature of the clinical field and the kinds of competencies that could be formally evaluated in a board examination. Once the proposal had been submitted to ABMS in 2010, a multistep evaluation began, including an assessment and approval by each of the member boards. What made the clinical informatics proposal especially unusual was the notion that it should be possible for a physician to be certified in the clinical informatics subspecialty regardless of which board had provided the clinician's primary certification. Of course, to those of us in the informatics field, it makes perfect sense for a physician to be an effective clinical informatician, regardless of whether the person's primary specialty is internal medicine, family practice, radiology, surgery, pathology, or any of the other fields represented by boards within the ABMS. Typically, all subspecialty candidates for a given examination were previously certified by the same parent board (eg, all cardiology subspecialists must first pass their board exams in internal medicine). With the support from all the boards, the proposal was referred by ABMS to its committee on certification, which then considered the proposal in great detail. There were two ‘readings’ scheduled in February and July of 2011 at ABMS headquarters in Chicago where I joined the executive director of ABPM to answer questions and generally to support the proposed subspecialty. One recurring question was whether informatics was sufficiently ‘clinical’ to qualify as a medical specialty. In parallel, we had been discussing the proposed subspecialty with the Accreditation Council on Graduate Medical Education (ACGME), which accredits training programs in medicine (residencies and fellowships) and which accordingly would be the accrediting body for our informatics training programs. The ACGME, after learning more about our programs at the 2010 meeting of the AMIA Academic Forum in Denver, had adjusted their own definition of the word ‘clinical’ as follows: ‘Clinical: Refers to the practice of medicine in which physicians assess patients (in person or virtually) or populations in order to diagnose, treat, and prevent disease using their expert judgment. It also refers to physicians who contribute to the care of patients by providing clinical decision support and information systems, laboratory, imaging, or related studies.’ This definition, once adopted by the ACGME, became strong evidence that others viewed informatics as ‘clinical’ and led to a positive vote by the committee on certification regarding the clinical informatics subspecialty proposal. This key approval led to early coverage in the medical press5 and generated great enthusiasm by individuals who had been monitoring the proposal and approval process for over 2 years. Finally, on September 21, 2011, the full board of the ABMS approved the new subspecialty and this long ‘birthing’ process was able to enter a new phase. The current plan is for clinical informatics subspecialty board examinations to be offered by ABPM starting in the autumn of 2012. For the first 5 years, practicing clinical informaticians will be able to apply for board eligibility based on their work and experience in the field. Formal criteria for such practice-based eligibility will be announced by the ABPM. One requirement, of course, will be that the applicant must already be board certified in a primary specialty by one of the ABMS boards. After the first 5 years, all candidates will need to have completed a fellowship in clinical informatics that is accredited by the ACGME. There is thus a 5-year period during which new and existing fellowships will need to be created and assessed by ACGME so that their graduates will be board eligible. The AMIA Academic Forum has been working with existing training programs to provide education about the ACGME accreditation process and to assist in the adaptation of existing fellowships to comply with ACGME requirements. Although the certification process will be overseen by the ABPM and one or more co-sponsoring boards (the American Board of Pathology has already asked to be a co-sponsor, and two other boards have also expressed an interest in doing so), AMIA will be providing support in a variety of ways. First, we solicited self-nominations from AMIA members who are interested in serving on the ABPM clinical informatics examination committee, which will be responsible for writing examination questions based on the identified competencies for those who wish to be board certified. Several names were forwarded to the ABPM and we expect several AMIA nominees to be appointed to the question development committee. Second, AMIA is already well along in designing board review courses that we will offer for those who are preparing to take the certifying examination. We have also recognized that many superb clinical informaticians will be ineligible for the subspecialty certification being offered by the ABMS/ABPM process. In particular, the certifying examination will be unavailable to non-physicians or to physicians who lack specialty certification through one of the ABMS boards. Nurses, pharmacists and PhDs who are working full time in clinical informatics environments clearly need a similar kind of certifying opportunity, and AMIA is committed to developing such options for all our members who wish to pursue clinical informatics certification. With these additional potential candidates for certification in mind, AMIA's Academic Forum has appointed a task force to consider options for providing a certifying process for those who are ineligible for the ABMS board examination. That task force will be reporting soon to the forum leadership, and in turn to the AMIA board. As plans develop and we have definite news to report, information will be provided to members through our regular newsletters and on the clinical informatics page on the AMIA web site.6 We welcome your comments and suggestions. The purpose of the Messages from AMIA section is for AMIA to communicate and involve its current and potential members in AMIA. The messages on these pages reflect the goals and direction of AMIA's board of directors and leaders only. These pages are designed to inspire members and readers to connect with the association on strategic objectives and activities. We hope you will find them a useful tool for keeping connected to AMIA leadership. We welcome your thoughts and feedback. None. Not commissioned; not internally peer reviewed.

Rapid technological change has affected many aspects of our society, but perhaps none more profoundly than the world of publishing. Scientific journals largely have moved to primary publication online. Clinicians and researchers first learn of, and then read articles on the Internet—and print them locally when required. Thus, as all publishers, whether commercial or non-profit, have attempted to address online communities, they have had to reconsider their business models and track new opportunities. The end of the current five-year Journal of the American Medical Informatics Association (JAMIA) publisher's contract in 2009 afforded the American Medical Informatics Association (AMIA) the opportunity to reconsider seriously its plans for the future of the journal. Thus, in May 2008, following an invited presentation by the Editor-in-Chief regarding the current status, perceived opportunities, and important decisions to be made for JAMIA, the AMIA Board of Directors began work on the renewal of the publishing contract for its flagship journal. The AMIA Board charged a task force comprising representatives from the Board of Directors, the AMIA Publications Committee, AMIA Staff, the JAMIA Editor, and a seasoned scholarly publishing consultant to assess future publishing options and to then issue a request for proposals. The task force convened frequently (electronically) during the first few months of its work, to examine the overarching principles of the process, to study the current publishing model, and to explore alternative approaches to publishing the association's scholarly journal. As their first order of business, the task force conducted a survey of all AMIA members to solicit comments on a variety of possible approaches. The survey asked members to indicate their personal preferences for five different publishing models, which included combinations of various options of print, online, and open-access versions of JAMIA. The survey results indicated that AMIA members' most favored (70%) overall model was the combined availability of print and online JAMIA versions. The ‘open-access only’ model was rated least desirable, due to the high per-article publication costs that all authors would have to pay. In the autumn of 2008, the task force developed a request for proposals (RFP), heavily influenced by an analysis of the data from the member survey. The RFP was released in December 2008 and sent to 11 publishers. Five bidders submitted proposals in early 2009. The task force analyzed the proposals, taking into account those solutions that would advance JAMIA's leadership position in the field of biomedical informatics, and those that would implement best practices and best evolving technologies. The task force ranked proposals based on criteria covering vision, innovation, quality, cost, marketing, and support. It considered the ability of the publisher to provide extraordinary service to authors and to the Editorial Office, to deliver an exceptional product, and to assure diversification of publication revenues. Three publishers were ultimately selected as finalists to make presentations to the task force in early May 2009 in Bethesda, MD. In a series of sessions held on the same day, the three finalists presented overviews of their proposals and entertained clarifying questions from Publisher Selection Task Force members. Immediately after the candidate publishers' presentations, the task force met to select which publisher it would recommend to the AMIA Board of Directors as the next publisher of JAMIA. In order to make the best selection, the task force focused on 14 evaluation criteria (as developed by Morna Conway, AMIA's consultant) and the weighting that each would carry. The task force members each assigned scores to each candidate publisher based on the evaluation criteria, and considering the written proposals, the oral presentations, and the responses to task force member questions, and intangible aspects. In the end, the task force voted unanimously to recommend the BMJ Group as the next JAMIA publisher. All task force members agreed that while there was higher risk for this strategy, due to the distance of London from the USA and various other factors, there was also the potential for a much higher reward for JAMIA both in recognition and impact (eg, close association with a highly regarded and widely circulated clinical journal), and in the potential for significantly enhanced financial returns to AMIA. The BMJ Group has been at the leading edge of innovation in electronic publishing and in promoting evidence-based medicine in the clinical arena. After receiving the final report and recommendation from the task force, the AMIA Board of Directors voted to invite the BMJ Group to serve as the next publisher of JAMIA, beginning with the January 2010 issue. The BMJ Group is a wholly owned subsidiary of the British Medical Association. It is based in BMA House on Tavistock Square in London. They have over 310 staff worldwide with 20 staff in the USA, including six physicians. They publish the British Medical Journal (BMJ) plus 30 specialty journals, for which the BMJ Group has 10 editors-in-chief based in North America. The AMIA Board decided that the BMJ Group would be more likely to extend JAMIA's (and AMIA's) brand, prestige, and impact through its high-profile presence and innovative publishing practices, as well as its market strength in the healthcare arena. The Board believed that JAMIA would thrive intellectually, enhance its electronic publishing functionality, and increase its relevance under the BMJ Group. The reviewers found several key points attractive in the BMJ Group's proposal, including: guaranteed income to AMIA for 2009 and beyond (with the potential for significant increases), direct association with the BMJ brand, change of access policies to maximize revenues, development of new revenue streams, transition costs covered by BMJ Group, plans to introduce a range of dynamic interactive features, and the opportunity to interact and share best practices with other international journal editors. The BMJ Group proposed a major focus on the journal's revenue growth, including enhanced direct marketing, streamlined management of the renewals process, the introduction of Web 2.0 features to build usage, and the nurturing of more extensive media contacts. The BMJ Group's proposal envisioned dynamic online JAMIA features. Potential examples included regular blogs, podcasts, and video features. Other online features might include topic collections, e-letters, and a JAMIA online community, as well as the bolstering of JAMIA's existing RSS feeds and data supplements. For authors and reviewers, the most prominent JAMIA enhancement will likely be the addition of Bench>Press, an online manuscript submission system developed by HighWire Press at Stanford University, in conjunction with BMJ Group. Compared with past JAMIA practices, Bench>Press offers a more accessible, available, and reliable method to submit manuscripts. Previously, authors were asked to submit their manuscript files via an FTP server, and to then correspond with the JAMIA Editorial Office by email. While this process provided a secure and relatively fast way to transmit files, a majority of JAMIA authors found the FTP process somewhat difficult. With Bench>Press, however, only an internet connection is needed and the submission instructions are very straightforward and easy to understand. The Bench>Press system, most importantly, will provide an online mechanism for authors to track the progress of submitted manuscripts through the JAMIA peer review process—something Editorial Office email did not support well. Another change authors will appreciate is the elimination of the PDF file requirement for submission. Bench>Press, as part of the submission process, will create a PDF version of the manuscript from the submitted text file. Authors will be responsible for checking the resulting PDF to make sure the conversion was successful. Authors will also be responsible for providing print-worthy figures before the manuscript enters the review process as opposed to after the manuscript has been accepted. Now, instead of including figures at the end of the manuscript file, each figure must be submitted as a separate file. The figure files will be uploaded along with the main manuscript file and checked for printability as part of the PDF conversion. If a figure is deemed not fit for print, the paper's corresponding author will receive notification along with a request to submit a figure file with better resolution. The submission will not enter the review process until authors have uploaded an image with better resolution. As part of the transition to the new publisher, and after much deliberation regarding the tradeoffs involved, AMIA is adjusting its policy regarding deposition of published articles from JAMIA into PubMed Central. As in the past, AMIA will retain exclusive rights to publish those submissions that can be copyrighted, but we will adopt a policy already pioneered by the BMJ Group whereby authors retain copyright on their articles (if copyrightable), and assign exclusive rights to publish and distribute the article to BMJ Group and to AMIA. This will allow authors, for example, to make copies of their work for non-commercial purposes (eg, for distribution to students in courses) without asking permission. The BMJ Group will provide assistance to assure that the final versions of all articles will be available in PubMed Central. The new publication process will continue to be compliant with all NIH (and certain other government or foundation funding agencies) requirements for open access 12 months after publication. Per the new publisher contract, those articles not covered under the NIH policy (or its equivalent) will not appear in PubMed Central until 36 months after initial JAMIA publication. To ensure a smooth and appropriate transition for authors, all accepted JAMIA articles that were initially submitted before January 1, 2010—that is, prior to the announcement of this change in policy—will be deposited in PubMed Central after 12 months (consistent with the prior policy). Of course, all articles will be available to AMIA members and to institutional and individual subscribers immediately via the JAMIA web site. The BMJ Group and AMIA will also provide an ‘unlocked’ option, whereby authors may pay a fee prior to publication to have their paper freely available, both in PubMed Central and on the JAMIA site, immediately upon first publication under a Creative Commons license. Details of the PubMed Central arrangements, as well as the ‘unlocked’ fee for 2010, and other ‘instructions to authors’, will be regularly updated on the new JAMIA website. This will include further details on authors' new rights with regard to the sharing of their accepted manuscripts on personal or institutional websites. Although these changes in policy will delay the release of certain JAMIA materials for free access, we will be working to attract more readers to JAMIA's own website, where we will be introducing new features and opportunities not available either in the print journal or on PubMed Central. We will be working closely with BMJ Group to monitor both the impact on revenues and the numbers of downloads, as well as JAMIA's impact factor. We are excited to share with readers some of the detailed plans for JAMIA's transition to a new and dynamic publisher, BMJ Group. The authors and the AMIA Board all believe that this is an important step forward to a better future for the journal. We will share more details with readers in the months ahead. We trust that AMIA's members, and all JAMIA readers and authors, will be pleased to see the evolution to a more timely and dynamic publication model that suitably leverages the new technologies, while continuing to provide the kind of quality articles and rigorous science that you have all come to expect of JAMIA. Comments to the AMIA leadership and to the JAMIA Editor are welcome as we move forward into the new world that lies ahead. AMIA would like to thank those individuals who served as members of the Publisher Selection Task Force: Dominik Aronsky, Morna Conway, Don Detmer, Sherrilynne Fuller, Karen Greenwood, Brian Haynes, Nancy Lorenzi, Randolph Miller, and William Tierney. None.

The American College of Medical Informatics is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline now known more inclusively as biomedical informatics, is the Morris F Collen Award. Dr. Collen's own efforts as a pioneer in the field stand as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. At most once a year, the College gives its highest recognition to an individual whose attainments have, throughout a career, substantially advanced the science and art of biomedical informatics. In 2008, the College was proud to present the Collen Award to Robert A. Greenes, MD, PhD (Figure 1). ‘Bob’ Greenes, who like Dr. Collen himself was one of the pioneers in biomedical informatics, has had multiple achievements as a physician, computer scientist, researcher, educator, and eloquent spokesperson for the field. His career contributions make him most deserving of the recognition embodied in the Collen Award. Robert A. Greenes, M.D., PhD 2008 Collen Award Recipient. Bob was born on June 17, 1940 in Cleveland, OH. His parents owned a hardware store in the Polish neighborhood where he and his sister grew up. Upon graduation from Cleveland Heights High School, Bob did undergraduate work at the University of Michigan, where he majored in zoology and took a course in computing (Fig 2). He entered Harvard Medical School in 1962, where he looked for individuals doing work with computers in medicine and quickly sought ways to become engaged in clinical computing research. He later noted: I've had the wonderful luck and opportunity to begin my career in the field of biomedical informatics much at the same time that the field itself was beginning to take shape. In 1964 Octo Barnett1 came to Massachusetts General Hospital (MGH) to run the hospital portion of a project called ‘The Hospital Computer Project. I joined this project as soon as I learned about it. There was a lot of naïveté and optimism in those days. The idea was to implement a time-shared operating system on a PDP-1 computer, using teletype machines connected by 10-character-per-second modems. It was one of the first time-sharing systems in the country. Neil Pappalardo, Curt Marble, and I began to think about the possibility of developing medical applications using a new operating system and computer language that we would develop on a PDP-7 computer in the laboratory. Bob Greenes as undergraduate student, University of Michigan. This novel computer language evolved during the 1960s into what became known as the Massachusetts General Hospital Utility Multiprogramming System (MUMPS) and it formed the basis for many early applications at MGH. Closely involved with the development of MUMPS was Dr. Octo Barnett, who would later say of Bob Greenes: He was one of a brilliant group of young computer-niks who created a new language and a new vision of the potential role of computer technology in medical care. With the development of MUMPS, the Hospital Computer Project was awarded a grant from the NIH. Although the novel system was very limited in memory and speed by modern criteria, a series of remarkably successful applications emerged from the MGH group over the next few years.1–4 Some 40 years later, MUMPS (which has since come to be known as “M”) continues to be heavily utilized for both medical and nonmedical applications. Upon graduating magna cum laude from Harvard Medical School in 1966, Bob took what was an unusual path at the time. Instead of pursuing an internship and residency, he applied for a postdoctoral grant from the NIH to pursue his PhD in Applied Mathematics (with an emphasis on computer science) at Harvard. To our knowledge, he thus became the first physician in the country to obtain such a doctorate. This type of MD/PhD training later became a critical component of many biomedical informatics programs in the United States. Referring to his PhD training years, Bob has noted: This was a wonderful opportunity because the program was very flexible. I was able to take courses at both Harvard and MIT, including a course in decision and control taught by Howard Raiffa, one of the fathers and founders of the field of decision science. I decided to do a thesis on structured capture of progress notes by physicians' data entry in a hypertension clinic at Mass. General Hospital. To do this project, with the help of engineers we developed a touch-screen computer interface to a CRT display terminal. We did this by pasting aluminum strips on the screen at points where selections could be made and connecting those strips with wires to a capacitor circuit (Fig 3). Cathode-ray tube display terminal used at Massachusetts General Hospital in the late 60s. The touch screen input was based on capacitance sensitive strips underlying lines of text. Also involved in this early research was Edward H. Shortliffe, MD, PhD, President and CEO Designée for the American Medical Informatics Association and recipient of the 2006 Collen award: I was personally excited to hear that Bob Greenes was selected as this year's Morris Collen awardee, since Bob has been arguably the single most consistent influence on my professional career since my early days as a Harvard undergraduate when I went over to Octo Barnett's lab and was paired-up with Bob as his research assistant while he was doing his PhD in the late 1960s. The field that we now call biomedical informatics was unrecognized as a discipline at that time, and others have pointed out that Bob Greenes was a visionary in his appreciation of what was coming and the kind of professional commitments that were needed. For example, Milton Corn, MD, Director of Extramural Programs at the National Library of Medicine, has noted: I think there was some appreciation, some ability to see the future, in Bob, that made him realize long before almost anybody else that the role of the computer in improving health care was going to be enormous … and he took a chance. After completing his PhD, Bob briefly worked in the commercial world, serving as President of a young company, Automated Health Systems, Inc, that sold MUMPS-based clinical information systems into the hospital marketplace. Recognizing that he preferred the academic research environment, Bob then jointed the faculty at Stanford Medical School for a year. However, he determined that he needed to complete his clinical training to have the kind of impact that he desired, so he returned to Boston to pursue a residency in radiology at Massachusetts General Hospital. After completing his training, he joined the Harvard Radiology Faculty, based at the Brigham and Women's Hospital, where he combined his clinical work in radiology with a rapidly growing research and education program in clinical informatics and decision support. He benefited from the strong support of his departmental leadership, one of whom, Professor and Chairman Steven Seltzer, would later say of Bob: The way I really got to know Bob was that for almost 20 years we shared an office cluster. It showed me that Bob had many special characteristics above and beyond his great intellectual talent as an informatician and as an excellent diagnostic radiologist. It showed me that he was patient, that he was flexible, that he was willing to share, and that he was always a good colleague and friend. Upon completing his medical training in 1978, Bob founded the Decision Systems Group (DSG), a research and training unit within Brigham and Women's Hospital's (BWH) Department of Radiology, which currently has over 100 alumni, many of whom have taken lead positions in academia and industry around the world. Bob continued to develop applications for use in the clinic (Fig 4), 5 and to contribute to the evolution of MUMPS.6 He also worked on a system for measurement, calculation, reporting, and retrieval of obstetric ultrasound examination,7 and a graphical tool for clinical decision support.8 Bob Greenes in the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School. In the late 70s and early 80s, the fields of medical informatics and health decision sciences were not yet as specialized. The Boston area had a large number of faculty whose research was dedicated to medical decision analysis. In this rich environment, Bob collaborated with several pioneers in health decision sciences, such as Barbara McNeil, Stephen Pauker, Milton Weinstein, and Colin Begg. Bob published results of his decision analysis research in Medical Decision Making, then in its third year of existence,8 as well as several other journals.9–12 He collaborated with his former mentor, Octo Barnett, and Rita Zielstorff in the first IAIMS grant to Harvard Medical School.13 At the DSG, Bob led several federally funded projects related to medical knowledge management and decision support. A key contribution of the DSG was its role in the development of the Unified Medical Language System (UMLS). Dr. Betsey Humphreys, Deputy Director of the National Library of Medicine, has noted: In my mind, Bob Greenes will always be associated with the early years of the UMLS project. He was at that time utterly consistent, and throughout the rest of his career as well, in saying that what we really needed were some good tools that would make the UMLS resources more useful and usable to people. So Bob was really ahead of the curve and brave to be working solely or heavily on the tool side when there was absolutely nothing like platform independence (in fact, in a period in which platform independence was a pipe-dream). The UMLS effort was precedent setting, not only for the results but for the way in which the coordinated project, with contracts from the NLM to several leading informatics research sites, brought people together across institutional boundaries and showed how collaboration could work at a distance and with crucial involvement by trainees as well as faculty members. Bob Greenes would later note: I've come to believe that informatics is a terrific vehicle for social engineering. If one has a good idea and can bring people together to test it, to explore it, to expand on it, and to use it, we've actually created something that was not there before. Bob supervised research on information retrieval by one of his first trainees, Dr. William Hersh.14 He also addressed practical problems at the Department of Radiology by developing practical computer-based solutions. For example, derivatives of pioneer work on a structured reporting system for ultrasound studies, developed by Dr. Doug Bell under Bob's supervision, are still in use at BWH.15,16 Another early trainee, Dr. Rick Shiffman, worked on the representation of clinical practice guidelines as decision tables.17 Bob allowed his trainees to explore their own ideas, but also brought them back firmly to well-grounded problems that could be tackled effectively and in the time available to them. As Dr. Shiffman (now an associate professor at Yale University) recalls: Among the first projects I proposed to Bob was creating an expert system to help with the diagnosis of dysmorphic children. At the time Bob himself was thinking about knowledge representation using algorithms. And he counter-offered a suggestion that I pursue a problem he was wrestling with. Now one of Bob's most enviable qualities is his ability to focus on a problem until it gets solved. Each month I'd offer a fresh expert systems proposal at our meetings and each month he'd patiently re-describe for me the issue with the CAT scan, and how he thought it'd make a good fellow project. Dr. Bill Hersh, Professor and Chair of the Department of Medical Informatics and Clinical Epidemiology at the Oregon Health and Sciences University, also has fond memories of Bob's mentoring skills: An important aspect of Bob's mentorship is that he taught me how to be a mentor … he showed me that it's not just a matter of teaching someone or critiquing their work, but really keeping an eye out for their career and the directions that they're headed. Another former trainee, Dr. Luke Sato (Chief Information Officer for the Harvard Risk Management Foundation), notes: I was just really struck with the sophistication, the innovation, and the out of the box thinking that was taking place in his laboratory. He really forced us to think non-traditionally and challenged us on our assumptions and forced us to think beyond what was really capable at the time. These themes are often recapitulated by other trainees, such as Dr. Steven Labkoff, now a Senior Director with Pfizer's Global Business Unit: One of the most compelling things about working in the DSG was best summed up in a poem by Edgar A Guest. The poem was, “It Couldn't Be Done”. The poem outlines stepping up to huge challenges. It summed up Bob's philosophy about our projects. He seldom if ever said “it can't be done”, or “you can't do that” in general. In point of fact, the lab was a place which encouraged me to push the envelope, test the limits, and where possible, break through. It was this kind of creative freedom that helped me to try ground breaking things. It is a philosophy I've kept with me throughout my career in the business world. Bob led a group of talented physician trainees and computer scientists in the exploration of several new technologies that later became mainstream in informatics, such as a web-based prototype for scientific journal publishing in the mid 90s (a prototype for the New England Journal of Medicine's online publication was developed at the DSG),18 and a web system for Partners Healthcare System (a merger of BWH and Massachusetts General Hospital, two of the academic medical centers affiliated with Harvard Medical School).19 Other contributions from this period include participation in the InterMed Collaboratory,20 a consortium of leading medical informatics centers from 1995 to the early 2000s involving medical informatics researchers from Columbia, Stanford, McGill, and Harvard Universities. As part of InterMed, the GuideLine Interchange format (GLIF),21 a model for representing and sharing guidelines in a computer-interpretable format, was created. Under Bob's leadership, this line of research, as well as many others, was continued at the DSG (Fig 5). 22 GELLO, an expression language for GLIF, later became an HL-7 standard.23 Bob and the DSG family and friends (2007) Front: Lucila Ohno-Machado, Carole Greenes, Bob Greenes, Octo Barnett. Middle: Rosa Figueroa, Qing Zeng, Hyeon-Eui Kim, Ronilda Lacson, Staal Vinterbo, Margarita Sordo. Back: James Signorovitch, Esther Shilcrat, Christopher Tsai, William Solomon, Pankaj Sarin, Sassikiran Kandula, Sergei Goryachev. In 2005, at the celebration of the 25th anniversary of the DSG, Bob became the first incumbent of the Distinguished Chair in Biomedical Informatics at BWH and also received a leadership award from AMIA. Over 200 colleagues, family, and friends from around the world came to the Harvard Faculty Club to celebrate this memorable event. Bob founded and was the director of the BIRT program for 15 years. The BIRT program is the program in biomedical informatics, with and postdoctoral trainees who research in biomedical informatics in the Boston This consortium of MIT, and Boston Bob worked with Professor from in the of a program in medical informatics at the of Health Sciences and of The program was in and has over who now several positions in the industry and and are the Department of and Computer at or the Department of Health Decision at Harvard. his role as training program director and director of one of the that the Bob had the opportunity to with several trainees, and from (Fig His in this role to Bob's leadership and continued to education in biomedical informatics. The of his role has been not only by his trainees and colleagues, but also by such as Dr. Director of the National Library of I think Bob more to to and on to a I think he a problem as an opportunity for and what a good to begin with. I can years he was very with in the had some programs that allowed to make and of almost and he got a lot out of he used in this teaching so that a could ahead and develop a problem by the and of program I think he has been an excellent to many people. training program faculty Octo Barnett, Howard and Bob Bob in many on and academic and he on the Biomedical Library of the National Library of which he as Chairman in as well as in other at NIH. A fellow of the American College of Medical Informatics since year in which the was he to positions of leadership in a number of professional including the American Medical Informatics the of and the American College of He was President of the American College of Medical Informatics in and for many years on the Radiology Information Systems He is also a at and where he not only his own research but also often is to that his knowledge of the field and his ability to the that from computer and hardware to both the clinical and medical In he was to in the of of the National of Bob Greenes has over 200 in the fields of medical informatics and is an associate of the Journal of Biomedical He is the of a Clinical Decision the published by (Fig Bob also two to the now Biomedical Computer in Health and and Bob Greenes: Clinical Decision The After that kept Bob and his Carole in Boston for most of their both of their professional were in their decision to their and positions at University in and Bob was by the opportunity to as of a new Department of Biomedical created at as part of their contribution to a new medical in created with the University of The University of College of in with University brought a new medical to the in the United and the only United a medical The University of College of was founded in in and has been the only School of in the It was established with strong support by and and with an early to biomedical informatics into the medical as part of a collaboration the two his new role in Bob has been an new with faculty and advanced He and his have the new program in a and he has his for what is in the The has out to be a very and … with the of collaboration and the to and things to health and One of his faculty Professor him in and helped to the program established before Bob was I to and to be the of the formed of biomedical informatics, one of my was to a One of the first that came to my was Bob his in informatics education and his as a in his field. The leadership has been remarkably visionary in the for an academic program in biomedical informatics and working to the The President PhD, has been that the has Bob Greenes to this leadership He came to from Harvard and has a our of biomedical informatics. more I think of this as an of the kind of impact he had throughout his he in and and Dr. Professor of Computer and Director of School of and Informatics (which is the to the new Department of Biomedical has the at which Bob has biomedical informatics and made it an part of many clinical research and academic in is of the kind of Bob in of able to things as well as with very Bob his novel and his to be a and his to be the first in our field to the important to which he to his time and His special contributions to medical decision and its have been as by Octo of the work of we in clinical decision have benefited by on Bob's It is and for his career and contributions to biomedical informatics to have been with the Morris Collen Award for

Don E. Detmer has served as President and Chief Executive Officer of the American Medical Informatics Association (AMIA) for the past five years, helping to set a course for the organization and demonstrating remarkable leadership as AMIA has evolved into a vibrant and influential professional association. On the occasion of Dr. Detmer's retirement, we fondly reflect on his professional life and his many contributions to biomedical informatics and, more generally, to health care in the U.S. and globally.

As the Editors of leading international biomedical informatics journals, the authors report on a recent pattern of improper manuscript submissions to journals in our field. As a guide for future authors, we describe ethical and pragmatic issues related to submitting work for peer-reviewed journal publication. We propose a coordinated approach to the problem that our respective journals will follow. This editorial is being jointly published in the following journals represented by the authors:Computer Methods and Programs in Biomedicine, International Journal of Medical Informatics, Journal of Biomedical Informatics, Journal of the American Medical Informatics Association, and Methods of Information in Medicine. As editors, we have collectively experienced at least one of the following occurrences recently: (1)Concurrent duplicate submissions: The same set of authors submits essentially identical manuscripts to two separate journals concurrently, without disclosure to the editorial staffs of either. The authors may mistakenly believe that it is permissible to do so because the respective journals have minimally overlapping audiences. (2)Serial unaltered submissions (“journal shopping”): Authors submit a manuscript to one biomedical informatics journal, and, after peer review, it is not accepted for publication, and a critique is provided. The authors do not make any of the changes suggested by the previous review and instead submit the unchanged manuscript immediately to a second journal, without disclosing the existence or results of the previous review by the first journal. (3)Serial minimally altered republication: Authors publish a preliminary manuscript as part of conference proceedings. Mistakenly believing that conference publications do not count as “official” publications (of note, several informatics conference proceedings, such as MEDINFO, MIE, and the AMIA Fall Symposium, are indexed in MEDLINE), the authors later submit the same work, with minimal alteration or expansion, to a peer-reviewed journal for publication. (4)Self-plagiarism1: Authors, mistakenly believing that any text that they have written is “theirs,” submit a new manuscript for publication in a different, peer-reviewed journal and include major sections (paragraphs or larger) of the previous peer-reviewed publication that they authored—and do so without proper attribution to the original source or without obtaining permission from the copyright holder. (5)Nondisclosure of conflict of interest by one or more of the authors: Authors with a financial interest related to the scientific content of the paper fail to disclose this information in a cover letter to the editor at the time of submission or in the acknowledgment section of the manuscript prior to the time of publication.

A 1985 graduate of Stanford University, Dr. Tarczy-Hornoch majored in biology but had already developed an interest in medical informatics. He maintained his interest and involvement during his years at Stanford Medical School and, after a pediatric residency at the University of Minnesota, moved to the University of Washington (UW), where he remains to this day. His neonatology fellowship from 1992 to 1995 did not prevent him from continuing to pursue his interest in medical informatics, and by 1995, he was playing the role of Clinical Informatics Lead on the University of Washington IAIMS grant. After joining the faculty in 1995, he assumed increasing responsibility for the nascent informatics program at UW, serving as Chair of the Curriculum Committee, Director of the Genetics Informatics Group, and currently as Program Director of their NLM Training Program in Biomedical and Health Informatics. Nationally, he served as Chair of the AMIA Genomics Working Group and helped found the IMIA Informatics in Genomic Medicine Working Group that he cochairs. Peter Tarczy-Hornoch As an undergraduate, Dr. Tarczy-Hornoch had formed his own software company (Sigma Medical Software, which specialized in software for biomedical instrumentation and decision support) and served as a key programmer on the Pathfinder project, a collaborative project that was later commercialized as Intellipath. Subsequently, after completing his house staff training, he pressed to create MINDscape, a Web-based EMR integrating access to knowledge sources and diverse clinical systems. Emerging as a prominent scientist working at the intersection of bioinformatics and clinical informatics, Dr. Tarczy-Hornoch has received numerous grants for work at this interface including his work on the GeneTests genetic testing resource and the BioMediator (formerly GeneSeek) biomedical data integration system. Dr. Tarczy-Hornoch has led the development of the UW Division of Biomedical and Health Informatics since 2001. Under his leadership, the UW informatics faculty has grown significantly, a PhD program has been approved, the program has received permanent funding from the UW, and the NLM has funded a UW informatics training grant. Unquestionably, the stature of biomedical and health informatics at UW has grown significantly as a result of Dr. Tarczy-Hornoch's inspired leadership. He has the ability to express a vision and convey it persuasively to both researchers and clinicians. After completing his education (BS in biology, SUNY at Stony Brook; MD, NYU School of Medicine), Dr. Wagner practiced internal medicine from 1979 to 1988 at Baltimore City Hospital, Bellevue Hospital, and with the Hawaii Permanente Medical Group. He then moved to Pittsburgh where he received additional formal training in artificial intelligence (PhD, Intelligent Systems, University of Pittsburgh) as a postdoctoral fellow at the Section for Biomedical Informatics under Randolph Miller and Gregory Cooper. He also practiced geriatric medicine until 2002. He joined the Pitt faculty in 1994 and has been an associate professor of medicine and of intelligent systems since 2001. Michael M. Wagner His research has focused on building information systems for clinicians and epidemiologists including the Benedum Electronic Medical Record (1991), CLEM (1996), a notification system (1997), the RODS system (1999), and the National Retail Data Monitor (2002). The RODS system is open-source software that is being used for public health surveillance in six states, five large cities, and one country (Taiwan). The National Retail Data Monitor collects and analyzes over-the-counter health care products for the purpose of public health surveillance, collecting daily sales data from more than 50% of the stores nationally that sell such products and making the data and analyses available in nearly real time to authorized public health users. His RODS Laboratory for real-time public health surveillance is well known and attracted a visit by President Bush in the post-9/11 era. Dr. Wagner has published in the areas of medical expert systems, data quality, and extensively in the area of real-time detection of disease outbreaks. A 1970 graduate of the medical program at Birmingham University in the United Kingdom, Andrew Grant earned a DPhil in Clinical Biochemistry from Oxford University in 1983 and then served as a lecturer at the University of Leeds until 1989. At that time, he was lured to the University of Sherbrooke in Quebec, Canada, where he is a professor of clinical biochemistry and Director of CRED (Collaborative Research for Effective Diagnosis). Andrew Grant Dr. Grant is a pioneer in medical informatics in Quebec and in Canada. His CRED group is concerned with diagnostics evaluation and technology application. His main research and application interest, which he has dubbed translation informatics, emphasizes knowledge and data communication and feedback at and across the different stages as a technology/therapeutic innovation progresses from research to accreditation to clinical use assessment. Dr. Grant has made ongoing contributions to the medical informatics field since 1991 in education (development of an online master's level program in medical informatics for health professionals), in the advancement of the field (establishment of a new society in Quebec [www.soqibs.org] with annual meetings including hosting the International Francophone meeting in Medical Informatics in 2002), in the training of highly qualified persons (co-PI in the establishment of the Pan-Canadian Health Informatics Collaboratory; he is a leader in an initiative toward large-scale collaboration for health informatics accreditation in Canada), and in research (health informatics program to support innovation and research, technology evaluation, and utility assessment) involved in cross-Canada collaborations. A 1983 graduate of the nursing baccalaureate program at the Federal University of São Paulo, Brazil, Heimar Marin quickly became committed to academic pursuits and served as Assistant Professor of Obstetrics and Nursing Informatics at that same institution from 1985 to 1991. During this time, she was working on her master's degree in nursing informatics (1991) and subsequently completed a PhD in medical informatics at the Federal University in 1995. After a postdoctoral fellowship at the Beth Israel Hospital and Harvard Medical School in Boston (from 1996 to 1998), she returned to São Paulo where she is now an esteemed senior faculty member in Nursing Informatics. Heimar de Fatima Marin In 2001, Dr. Marin was awarded a “Livre docente” in medical informatics. This is a credential awarded by a university at least five years after the doctorate based on additional course work, a new thesis, an annotated CV, and oral and written examinations. The holder of this credential is considered expert in all aspects of the discipline. Dr. Marin is the first Brazilian woman ever to receive this credential and the first nurse ever to be named Professor Livre Docente in Medical Informatics by the School of Medicine of the State University of São Paulo, Brazil's largest and arguably most prestigious school of medicine. Broadly trained and prolific in her research and educational innovations, Heimar de Fatima Marin is a leading medical informatician, not only in Brazil but also throughout Latin America. She works effectively through international organizations such as IMIA, the Pan American Health Organization, and the International Council of Nurses. Also an active member of AMIA, Dr. Marin has worked to strengthen ties between North American and Latin American informatics organizations. Outgoing and vivacious, she enriches both the social and scientific activities to which she devotes her energies. Knowledgeable and clear thinking, Dr. Marin is at once both diplomatic and outspoken. She is a proven innovator and leader whose accomplishments stretch beyond disciplinary and national boundaries. Betty Chang earned a BS and MA in nursing from Columbia University's Teachers' College in 1961 and then worked as an academic nursing educator for 16 years, first at Queens College in New York and subsequently at San Francisco State University. While on the SF State faculty in the 1970s, she worked on her DNSc degree in nursing care of the elderly, completing that training in 1977, and then moved to UCLA, where she has risen to a full professorship in the School of Nursing over the years. While at UCLA, she completed a certification in Nursing Informatics and became credentialed as a family nurse practitioner. Betty Chang Dr. Chang led one of the earliest research projects on knowledge-based systems in nursing. Funded by the National Institute of Nursing Research in the early 1980s, CANDI was designed to assist nurses with the process of generating a nursing diagnosis from the patient's signs and symptoms. Her recent research on consumer health informatics builds on a program of research on the elderly and their family caregivers and other vulnerable populations including those with HIV/AIDS. Dr. Chang is a respected senior nursing informatics scholar whose leadership in nursing informatics has spanned more than two decades. For the past 20 years, she has served as Departmental Editor on Nursing Informatics for Research in Nursing and Health, a highly regarded research journal. She has actively promoted the use of computers for nursing practice, education, and research and serves as a role model for nursing informatics innovation. During the past five years, Dr. Chang has led a number of consumer health initiatives for both AMIA and IMIA, leading an AMIA Symposium Post-Conference on the topic of consumer health informatics and, more recently, chairing the 2003 Spring AMIA meeting that focused on digital divide and the use of informatics in underserved populations. Professor Stephen Kay was awarded his BSc at the University of Staffordshire in 1976 and then moved to the University of Wales to work at their School of Medicine as an analyst programmer and systems manager while formally studying computer science, earning a master's degree in 1981. Although he moved to assume a position as lecturer in information systems at the University of Manchester's Department of Computer Science from 1987 to 1995, he continued to work on his doctoral degree at the University of Wales and received his PhD in 1995. He was then promoted to Senior Lecturer at Manchester and, in 2000, moved to the University of Salford where he is a professor of health informatics, Director of SHIRE (Salford Health Informatics Research Environment), and Associate Head for Research of the School of Health Care Professions. Stephen Kay Dr. Kay is a co-inventor (with Alan Rector) of the PEN&PAD clinical workstation effort. He also led the extended architecture component of the Electronic Health Record project that became CEN ENV13606 in 2000, which is well known and influential in our field. The current activities of the SHIRE group are important for their impact on standardization activities, nursing informatics, and studies in acupuncture. His research group is currently focused on clinical communication, and their research is themed with respect to clinical narrative, ontologies, standards, and learning. His collaborative work with Ian Purvis, summarized in an important paper entitled “Medical Records and Other Stories: A Narratological Framework,” appeared in 1996. Since then, Dr. Kay has continued to investigate the value of narrative theories applied to clinical records, practice, and organizational norms. Dr. Kay is also known for his role as director and designer of the first UK undergraduate BSc program in medical informatics at the University of Manchester during the 1990s. A biology graduate of Bucknell University in 1980, Dr. Lobach moved to the MD/PhD program at Duke University where he earned a PhD in immunology in 1986 and his medical degree in 1987. During his medical residency and an endocrinology fellowship, he became increasingly interested in medical informatics and earned an additional MS in medical informatics in the Duke program in 1994. Joining the faculty at Duke in 1995, he rose to his current role as an associate professor in both the Department of Community and Family Medicine and the Department of Biomedical Engineering. He has been Chief of the Division of Clinical Informatics since 1999. David F. Lobach Dr. Lobach's work has attracted wide attention since his first SCAMC paper the in 1994. He is known for his of the of clinical with systems. He has published a evaluation of this decision support in a and has to this of to feedback in a He has also developed a for of clinical and has a process for a A NLM Dr. Lobach is now Chief of the Division of Clinical Informatics in the Department of Community and Family Medicine at Duke University Medical He has a group of 20 faculty on to medical informatics research and at This group has the for academic medical informatics at Duke and has formed between the academic and senior level support staff for the Duke Medical After a degree in nursing and from College in on to a master's degree in nursing at the University of in and a PhD in 1986 in educational and computer She postdoctoral training in nursing informatics at the University of while she was an professor of nursing at the University of She was promoted to Associate Professor in and to a full professorship in with an additional in the School of and Dr. has been an educator and in the field of nursing informatics for more than 20 years. Her research the Nursing Data has to both of the and to of the between and and between and This research has also led to of the of data and use of knowledge in for knowledge building in clinical nursing Her to development of the Nursing Data is she currently with Dr. a collaboration by the International Medical Informatics and the International Council of to and an International Nursing Data Professor is for her in nursing informatics and nursing informatics She extensively and is an Professor at the University of Wales in the United as well as the of Nursing and of University of Dr. received her BS in from the University of in and a PhD in in from the University of After a postdoctoral fellowship in at she moved to Washington University where she in a of until 2001. Her interest in biology led her to a role at National Laboratory in and a role with the Division of Computer Research and at in 1991. in the Institute for Biomedical at Washington University, she a in to as Program Director for at the Since 2001, she has been an associate professor of computer at the University of with a in health and informatics since In Dr. a paper that computer to the The paper from her work at National Laboratory and was entitled in published as a in The of Her work from that time was the of her research on the of and use of to model of as systems. A member of the Biomedical and Informatics Committee, Dr. is also an the research of science, health informatics, and and Her work has the of is known biochemistry that the data be used to model than for that are the of has her development of new to the of and and the of A graduate of University, earned his from SUNY Stony in 1994 and then completed residency training in internal medicine and at Hospital and Hospital in New York He then moved to Boston for a medical informatics fellowship at the Laboratory of Computer Science at A in the SCAMC paper in both and Dr. on to the faculty at College of where he is now a professor of clinical and Director of that he of the first to formally as clinical he was also one of the in a use of the He to the development of the first EMR and an important role in the development of a for For more than a Dr. has the application of informatics in education be used both to education and to the of informatics in the academic and health care He has projects that that are to more health care of which in while to use informatics to a and impact on a medical He has a medical informatics that that graduate has an of the use of to a of medical an of and the impact of on and He is also interested in the by in to medical informatics and educational and Dr. completed his doctoral training in 1976 he earned a PhD degree from the University He was Head of Laboratory in the area of Informatics at the Institute of and Medicine at the same university from to In he has subsequently until the the Medical Informatics Department in the Institute of and Medical Informatics and completed a in Informatics in 2001. Dr. his research the of the with and international He his international in medical informatics after the of in a years, he developed an international as an expert in the field of of health care systems, and health care and their After years of international work, he published in the influential and of and Health Dr. is one of the medical the of system communication standards, in systems, and the He is actively in research in while on the development of a health care As an he be a highly for with such all of which to be research in biomedical informatics in the years. A graduate of University, David medical school at the University of his in After residency training in internal he became a fellow in internal medicine at the University of and a Clinical while working on his PhD at the He received the degree in He then while continuing at and the University of medical school as a member of the In he moved to the Health in San Francisco where he was a senior fellow for information technology and until he was to the Bush in early to as the first for Health in the of at the Department of Health and David Dr. in the informatics in medical school he his work on expert systems at SCAMC in 1983 and was awarded the in the paper He was also the first medical to on the of of the American Medical he is as a leader in health information technology and it the of and health He is one of the on health information and the use of in health During his years as and of the leading of medical and and Dr. led the company to more than to with research to the first health care and to create the first care process Dr. also designed and the development of the first health information technology and led first in In his new Dr. is in a position to a on and activities in the area of health information A biology graduate of Washington University in 1980, Dr. on for medical also earning a master's degree in the program in He completed his in 1987 and moved to for a in internal medicine. it was to New York for residency at Hospital, which he for two years his as Medical Director with the Group from to The of and him to where he joined the postdoctoral informatics program and, in time, to pursue a full PhD After completing his doctorate in he joined the faculty and is currently an professor of biomedical informatics and of at the College of and Dr. early work involved to the to support care but he on to important work in interface and evaluation, and, more recently, He is known for his work on the Informatics for and In this clinical of the elderly received and received Dr. designed the technology architecture and has been for system and of technology The of the was a to Dr. Dr. has served as faculty for the Informatics since has worked with graduate and has been active at the intersection of and informatics. His public and are by his past role as a member and Chair of the AMIA and his current position as of Dr. received both and from University in He on to an at Hospital in and then a medicine residency in 1985 at After two years in the he moved to the New Institute at University for He has through the at since 1987 and is now based in serving as the Health for Health He also the of Clinical Associate Professor in both the Department of and Health and the Department of Medical and Biomedical Informatics at the University of Dr. informatics led him to work with Dr. Andrew on the project to and data systems available to and public health as well as He subsequently served as scientist on the to and all of and and to available in an and In he developed and the first course in public health informatics, at the University of Washington School of The for this course the and of public health informatics as a field. recently, he and developed a new program at the to create a national public health information Health Dr. with fellow is to and to a of the field of public health informatics. David his undergraduate degree in from University in and then moved to the University of where he earned his degree in while a medical he was a programmer with the Group and his informatics until he became in his medical residency at the University of Medical from 1986 to 1989. He then to a fellowship in internal medicine and clinical at the Beth Israel Hospital and Harvard Medical School in leading to his as an from 1991 to 1999. He has been an professor of medicine since 2000, the for from to and Editor of since David M. Dr. has made contributions to medical informatics during his years at the Beth Israel Medical He that real-time from and systems and to the of on an medical a that is in the and He led a collaborative on the to and for health information over the This work was the first such and has been and used by with the and of health information Dr. was for the development of the used at the Beth Israel Medical He was also for for care this and for for and recently, Dr. was Program Chair of in He and this international meeting on the use of informatics in the HIV/AIDS. He also serves on the of the International of Medical Informatics and has served on the scientific program for two AMIA received his at University in and his at the University of in He then trained in at Hospital in and Hospital in from to After a fellowship in clinical and research at Boston City Hospital and Boston University in to 1977, he a in academic that led to his current position as Professor of at University in A fellowship in at in and then a with Dr. F. on diagnosis of in in Dr. of the the of informatics and decision at that time, he was a member of the for Medical and with computer a for work on clinical decision in to his at he is an professor in the Department of Computer and Science at the University of Dr. has that decision making be by decision and that the use of decision the of through his research, he has that decision support real-time for a clinical that is and be by the as to be subsequently by an of such as in be with and by to a His project, in collaboration with Dr. Dr. and has the of informatics in diagnosis and

In 2002-2003, the American College of Medical Informatics (ACMI) undertook a study of the future of informatics training. This project capitalized on the rapidly expanding interest in the role of computation in basic biological research, well characterized in the National Institutes of Health (NIH) Biomedical Information Science and Technology Initiative (BISTI) report. The defining activity of the project was the three-day 2002 Annual Symposium of the College. A committee, comprised of the authors of this report, subsequently carried out activities, including interviews with a broader informatics and biological sciences constituency, collation and categorization of observations, and generation of recommendations. The committee viewed biomedical informatics as an interdisciplinary field, combining basic informational and computational sciences with application domains, including health care, biological research, and education. Consequently, effective training in informatics, viewed from a national perspective, should encompass four key elements: (1). curricula that integrate experiences in the computational sciences and application domains rather than just concatenating them; (2). diversity among trainees, with individualized, interdisciplinary cross-training allowing each trainee to develop key competencies that he or she does not initially possess; (3). direct immersion in research and development activities; and (4). exposure across the wide range of basic informational and computational sciences. Informatics training programs that implement these features, irrespective of their funding sources, will meet and exceed the challenges raised by the BISTI report, and optimally prepare their trainees for careers in a field that continues to evolve.

InterMed is a collaboration among research groups from Stanford, Harvard, and Columbia Universities. The primary goal of InterMed has been to develop a sharable language that could serve as a standard for modeling computer-interpretable guidelines (CIGs). This language, called GuideLine Interchange Format (GLIF), has been developed in a collaborative manner and in an open process that has welcomed input from the larger community. The goals and experiences of the InterMed project and lessons that the authors have learned may contribute to the work of other researchers who are developing medical knowledge-based tools. The lessons described include (1) a work process for multi-institutional research and development that considers different viewpoints, (2) an evolutionary lifecycle process for developing medical knowledge representation formats, (3) the role of cognitive methodology to evaluate and assist in the evolutionary development process, (4) development of an architecture and (5) design principles for sharable medical knowledge representation formats, and (6) a process for standardization of a CIG modeling language.

OBJECTIVES: Many groups are developing computer-interpretable clinical guidelines (CIGs) for use during clinical encounters. CIGs use "Task-Network Models" for representation but differ in their approaches to addressing particular modeling challenges. We have studied similarities and differences between CIGs in order to identify issues that must be resolved before a consensus on a set of common components can be developed. DESIGN: We compared six models: Asbru, EON, GLIF, GUIDE, PRODIGY, and PROforma. Collaborators from groups that created these models represented, in their own formalisms, portions of two guidelines: American College of Chest Physicians cough guidelines [correction] and the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. MEASUREMENTS: We compared the models according to eight components that capture the structure of CIGs. The components enable modelers to encode guidelines as plans that organize decision and action tasks in networks. They also enable the encoded guidelines to be linked with patient data-a key requirement for enabling patient-specific decision support. RESULTS: We found consensus on many components, including plan organization, expression language, conceptual medical record model, medical concept model, and data abstractions. Differences were most apparent in underlying decision models, goal representation, use of scenarios, and structured medical actions. CONCLUSION: We identified guideline components that the CIG community could adopt as standards. Some of the participants are pursuing standardization of these components under the auspices of HL7.

Stanford's two decades of success in linking medical informatics and health services research in both training and investigational activities reflects advantageous geography and history as well as natural synergies in the two areas. Health services research and medical informatics at Stanford have long shared a quantitative, analytic orientation, along with linked administration, curriculum, and clinical activities. Both the medical informatics and the health services research curricula draw on diverse course offerings throughout the university, and both the training and research overlap in such areas as outcomes research, large database analysis, and decision analysis/decision support. The Stanford experience suggests that successful integration of programs in medical informatics and health services research requires areas of overlapping or synergistic interest and activity among the involved faculty and, hence, in time, among the students. This is enhanced by a mixture of casual and structured contact among students from both disciplines, including social interactions. The challenges to integration are how to overcome any geographic separation that may exist in a given institution; the proper management of relationships with those sub-areas of medical informatics that have less overlap with health services research; and the need to determine how best to exploit opportunities for collaboration that naturally occur.

The 1999 debate of the American College of Medical Informatics focused on the proposition that medical informatics and nursing informatics are distinctive disciplines that require their own core curricula, training programs, and professional identities. Proponents of this position emphasized that informatics training, technology applications, and professional identities are closely tied to the activities of the health professionals they serve and that, as nursing and medicine differ, so do the corresponding efforts in information science and technology. Opponents of the proposition asserted that informatics is built on a re-usable and widely applicable set of methods that are common to all health science disciplines, and that "medical informatics" continues to be a useful name for a composite core discipline that should be studied by all students, regardless of their health profession orientation.

To the Editor:— We read with great interest the recent article in JAMIA by Hendee, in which he called for the creation of a new NIH institute or center to support biomedical engineering, imaging, and informatics.1 We agree with much of his analysis but wish to offer some additional observations and alternative suggestions for how the informatics community might address the concerns that he has raised. The three cited disciplines clearly do “form the infrastructure on which many of the advances in medical science are built,” and we agree that they “must be nurtured and supported so that they will continue to function as the foundation for the knowledge revolutions of the 21st century.” We question, however, Hendee's claim that “there is no home at the NIH for the basic research that is essential to growth of the intellectual capital of these disciplines” and his characterization of the NIH as composed wholly of disease- or organ-specific research agencies. If one reviews the history of research in bioengineering, imaging, and informatics at the NIH, one will find that two entities have funded a large portion of both the basic and applied work in these fields, neither of which is disease- or organ-specific—the National Center for Research Resources (NRCC, formerly the Division of Research Resources or DRR) and the National Library of Medicine (NLM). Hendee refers to the NLM a few times in the article but fails to capitalize on what we believe is an obvious suggestion: the NLM is the natural home for an expanded intra- and extramural research program in bioengineering, imaging, and informatics. It would be much easier to expand the charge and funding for an existing agency than to create a new one. Furthermore, any new institute or center would, by Hendee's proposal, wrest from the NLM a body of research activities (informatics) that it has long nurtured and promoted, both internally and through its grants program. Furthermore, as Hendee notes, bioengineering, imaging, and informatics are today “experiencing a remarkable convergence spurred by several factors,” which makes even more logical the addition of bioengineering and imaging to the NLM's portfolio of activities. Active coordination or merger with some of the activities of the NCRR might also be appropriate in any such expansion of the NLM and its roles. We also question Hendee's assertion that correction of the current “utilitarian” multi-institute support for bioengineering, imaging, and informatics would ensure that resources “would be invested to support the basic science, engineering, and mathematics essential” to the growth and productivity of the three disciplines. It is unfortunately the case that computing, communications, and engineering have suffered from inadequate basic-research support in recent years, not only at NIH but also across all federal research agencies This was a major finding of the recent report of the Presidential Information Technology Advisory Committee,2 which led to their recommendations for enhanced support for basic research in information technology across all research-related agencies, including NIH. As was noted in the report, one key to accomplishing this at NIH is to push for recognition that “biomedically motivated basic research in information technology should be… viewed both as important information technology research and as fundamental biomedical research.” Until the culture of biomedical research in general, and of the NIH in particular, appreciates the fundamental issues that must be addressed by researchers in bioengineering, imaging, and informatics, we will continue to see the disciplines viewed as what Hendee calls “utilities whose purpose is to produce tools and techniques useful to the research missions of the individual NIH institutes.” Thus, any consolidation of research support for these fields in a reconfigured and expanded NLM will also require both an explicit NLM (and budgetary) commitment to basic research in the fields and a concerted effort to inform leaders and scientists at the other institutes about the fundamental roles that bioengineering, imaging, and informatics play in the evolution of all biomedical science. It is ironic that these proposals for the NIH are being discussed in the United States at precisely the time that a new set of biomedical research entities, the Canadian Institutes of Health Research (CIHR), is being created in Canada. In reviewing the plans for the CIHR (see the CIHR Web site at http://www.cihr.org/), we have been concerned to note that the proposal calls for the creation of multiple institutes that are organ- or disease-oriented, similar to those at the NIH, but without any evident consideration of the need for an entity to support research in bioengineering, imaging, and informatics. We find this troubling, since we are entering an era in which many of the most important breakthroughs are likely to occur at the intersections among traditional disciplines. Since the CIHR is new, it has a wonderful opportunity to create internal entities that will reflect such interdisciplinary opportunities and needs. A proposed CIHR institute that would appear to have an interdisciplinary focus is their Institute of Health Services, Clinical Evaluation and Technology Assessment. This would appear to be similar in motivation to the Agency for Health Care Policy and Research (AHCPR) in the United States, but the title suffers from not even recognizing its research focus explicitly. Altogether missing from the description of this proposed institute are additional, key, cross-cutting areas such as health-sciences educational research (including cognition as it relates to learning and decision making), bioengineering, imaging, and informatics. Thus, the Canadian proposal does not call for the creation of an organization with a charge similar to the intra- and extra-mural research program of the NLM, limited though the latter may be in light of our discussion above. In a letter to the Medical Research Council of Canada, one of us (V.L.P.) has accordingly urged that the CIHR consider creating an institute that would include the mandate of the NLM (but of course without the need to recreate the international library functions of the NLM). Such a new agency could still capture the notions of clinical evaluation and technology assessment but would appropriately broaden its charge to include informatics, bioengineering, and imaging while emphasizing the research, educational, cultural, and social issues that underlie the institute's goals and activities. Thus, the issues addressed in Hendee's article are topical and pertinent for the informatics communities in both the United States and Canada. We suspect that there are analogous issues arising in government research agencies in other countries as well. We accordingly urge a lively dialogue and effective educational and political efforts both in North America and more broadly in the international community.

The American College of Medical Informatics is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline of medical informatics, is the Morris F. Collen Award. Dr. Collen's own efforts as a pioneer in the field stand as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. At most once a year, the College gives its highest recognition to those whose attainments have, throughout their careers, substantially advanced the science and art of medical informatics. In 1999, the College was proud to present the Collen Award to Joshua Lederberg, PhD. Biologist, geneticist, computer scientist, and scholar, Dr. Lederberg's lifelong contributions to biomedicine and science, as well as to medical informatics, make him highly deserving of the recognition embodied in the Collen Award. Joshua Lederberg was born in Montclair, New Jersey, on May 23, 1925, the son of a rabbi. His interest in a scientific career was mentioned in an essay that he wrote at the age of seven. His family moved to New York City when Lederberg was a child, and Lederberg was able to attend Stuyvesant High School, a school that allowed him to concentrate in the sciences. In New York, Lederberg was also able to take advantage of facilities such as the American Institute, which made laboratory space and equipment available to talented high school science students. On graduating from high school at 16, Lederberg took advantage of a local scholarship to attend Columbia University and, after completing his undergraduate degree, he began medical school there. He did not see combat service during World War II, but from July 1943 he was enrolled in the U.S. Navy's V-12 training program, which combined an accelerated premedical and medical curriculum with active service as a hospital corpsman in a U.S. naval hospital. As a medical student, Dr. Lederberg undertook a series of experiments with Edward L. Tatum, demonstrating sexual recombination in bacteria. With his growing interest in a career in laboratory science. Lederberg decided to leave medical school to pursue a PhD, which he received from Yale in 1948 at the age of 23. After graduate school, Dr. Lederberg joined the Genetics Department at the University of Wisconsin, which at the time was part of the University's School of Agriculture. He eventually helped form the Department of Medical Genetics and served as its first chair. In 1958, when he was but 33 years old, Joshua Lederberg received a telegram of the sort that only a handful of scientists ever receive. He was awarded the Nobel Prize for “his discoveries concerning genetic recombination and the organization of the genetic material of bacteria.” He shared the prize with George W. Beadle and Edward L. Tatum, who won “for their discovery that genes act by regulating definite chemical events.” Joshua Lederberg demonstrating that his informatics work was “hands on,” even in the era of Model 33 teletypes. The work that led to Lederberg's Nobel award had begun in 1945, when he was 20 and still a medical student. Work published in 1944 inspired Lederberg to investigate the possibility of sexual reproduction in bacteria, which at the time were thought to reproduce only asexually. Lederberg's work, which formed the basis for his doctoral dissertation, demonstrated that bacteria can in fact reproduce through sexual recombination, and opened up the genetics of micro-organisms to the traditional methods of the field. These methods are now central to the fields of biotechnology and genetic engineering. Lederberg's name is today mentioned in most text-books of genetics and microbiology, not only for his demonstration of bacterial conjugation but also for his discovery of transduction and for his coining of the term plasmid to denote extrachromosomal genetic material. His scientific reputation was already established by the caliber of his work, but the Nobel Prize extended his reputation to the general public and allowed him to pursue his interests at the intersection of science, policy, and society. Between 1966 and 1971, he wrote a series of more than 200 articles for the Washington Post, which converted into lay terms many of the pressing scientific issues of the day. Typical articles addressed such themes as “Russian computers are having delusions—or are they?” and the premonitory “Congress should examine biological warfare tests,” a topic that continues to interest and engage him at the national level to this day. In parallel with his genetics research, Josh has had a long interest in formalizing the intellectual processes of scientific investigation and discovery and using computer models to represent these activities. He had used card-sorting techniques to help analyze the bacterial reproduction observations that led to his Nobel Prize years earlier, but on coming to Stanford in 1959 to found the Stanford Department of Genetics, his study of informatics took on new dimensions. He took classes in programming and began a series of systematic investigations of computer use in biomedicine. He introduced one of the first LINC computers into the Stanford Medical School and became principal investigator of a school-wide computer resource called ACME (Advanced Computer for Medical Experimentation). By the mid-1960s, Lederberg was working on ways to systematize the enumeration of chemical structures, especially molecular isomers—families of molecules with the same chemical formulas but with different arrangements of the atoms. This early work would find expression later on in the DENDRAL project.1 Comments by Donald A. B. Lindberg, MD, Director, National Library of Medicine: It's hard to remember when I really first met Josh, but I can remember vividly the first serious conversation I ever had with him. It was 1964, it was my first meeting as a Markel Scholar, the group was in the Ahwanee Lodge in Yosemite, and the speakers had been Jacob Bronowski, Le Dubridge, and Josh Lederberg. And I remember seeing Josh in the sun at a coffee break, sitting alone at a table, sort of lost in thought, and I decided that he probably wouldn't mind being interrupted. So I asked him what was he thinking about? It seemed like not too impertinent a question, although it probably was. And he said well, he was thinking about this: that if he had a chemical molecule in his mind, and he could see it clearly, what would be the next one that logically should be considered? Well, that struck me as kind of an amazing thing to be thinking about. With the post-Sputnik start of the U.S. space program in earnest, one of Lederberg's new areas of attention was the exploration of outer space in search of life forms. He coined the term “exobiology” to describe this new field, dealing with the search for the origins of life, and established the Instrumentation Research Laboratory to explore the synthesis of analytic instrumentation and computers to devise ways of detecting molecular signatures of life-related processes in planetary environments. This required inventing new instruments, such as fluorescence-activated cell sorting, and applying evolving instruments, such as gas chromatographs and mass spectrometers, in novel ways. It is also required inventing new ways to represent information about molecular structures such as proteins in the computer so that they could be analyzed and compared with each other. Work he performed in 1964 may have represented the first time that a protein sequence was stored in a computer for analysis. Comments by Edward A. Feigenbaum, PhD, Former Co-investigator of DENDRAL and SUMEX-AIM, Professor of Computer Science, Stanford University: In 1964, when I first met Josh, he was writing his first large-scale computer program, in a dialect of ALGOL. The program was called DENDRAL, for dendritic algorithm, but the reference to dendrites was metaphoric. Josh was creating a complete system for the enumeration of acyclic chemical structures. The system included: A notation in which each unique chemical structure was represented by a unique symbolic expression in canonical form. A graph manipulation algorithm for generating structures from molecular formulas. The DENDRAL algorithm was capable of generating structures exhaustively and without redundancy. A computer program to put the DENDRAL algorithm to work. In 1964, this was a landmark program not only for graph manipulation by computer but for application of computers to chemistry and life sciences, especially application of symbolic processing methods. When I arrived at Stanford in January 1965, I discussed with Josh my goal of creating models of the thinking processes of scientists, especially the processes of empirical induction with which hypotheses and theories were inferred from data. What I needed was a specific task environment in which to study these issues concretely. Josh suggested a task of inferring organic chemical structures from mass spectral data and enthusiastically entered a collaboration. He suggested a generate-and-test approach, in which the DENDRAL program he had done would serve as the “legal move generator” in the heuristic search for plausible structural hypotheses. The program we built, with the help of Bruce Buchanan, was called Heuristic DENDRAL. We extended its performance greatly in both breadth and depth when Carl Djerassi joined the collaboration. Josh brought this about, conveying to Carl the importance of the work. Josh's enthusiasm was infectious. My sketch of Lederberg and DENDRAL is necessarily brief and leaves out many of his tangible contributions to our work in artificial intelligence and its applications. And it leaves out almost all his intangible contributions—the texture, if you will, of the day-to-day interactions with Josh. These interactions were full of wisdom and guidance on how to run substantial interdisciplinary projects of the kind we were doing in expert systems, insights on the nature of knowledge and cognitive processes in science, and creative ideas for getting us over today's hurdle and tomorrow's hill—in truth, a flood of creative ideas. If we had had the energy and resources, we could probably have done ten other projects with these ideas. Working with Josh on our common problems in modeling expert thought in science and biomedicine gave me the privileged opportunity to witness a great intellect at work, applying superb analytic thinking skills with the enthusiasm of a young hacker for how much fun it was to program a computer to do these things. And it was not only fun, but it was important in the history of computer science. The DENDRAL collaboration led Josh to devote a great part of his energies to computer science, including the underlying languages and tools necessary to express his ideas about molecular biology and genetics. Comments by Donald A. B. Lindberg, MD, Director, National Library of Medicine: I was walking across the lovely campus of Stanford with him, following a morning in which I don't remember the real circumstances, but a whole lot of very nice research was reported at Stanford. I must confess, while I liked it all, I was sick and tired of hearing about LISP and list-processing languages. So as we hiked off to the commissary or the faculty club or wherever we ate, I said to Josh, “Josh, what would happen if some malignant deity just all of a sudden destroyed, eliminated, LISP. There isn't any more LISP. What would you do?” And he said “Oh, well, I guess, Don, I'd take FORTRAN and write LISP.” Lederberg insisted on participating first-hand in the development, testing, and use of the computing systems that fascinated him, no matter how cumbersome the early human—computer interfaces were. The breadth of Josh's biological, chemical, and computer science knowledge allowed him to serve as the bridge or glue among the interdisciplinary teams he assembled. Comments by Carl Djerassi, PhD, Former Co-investigator of DENDRAL, Professor of Chemistry, Stanford University: When I came to Stanford in 1960, Josh was probably my closest friend, professionally and personally, and within about two years we started to collaborate, I as a chemist, he as a person who works in every field conceivable, including even chemistry. At that time he was interested in exobiology and unmanned flights to outer space and felt that whatever information we needed would get back through telemetry and that, in order to determine if there was any life in outer space, we had to look for certain evidence of life out there. I was involved at that time in the area of mass spectrometry and, precisely, materials that would be related to things in outer space. Steroids, of course, are an example of something that you are unlikely to find up there. So we got together with Ed Feigenbaum, who had been working on artificial intelligence in general, to see what we could apply to chemistry, in particular the structural elucidation of organic compounds, which was precisely my area. And then they came to me and said, “Look, can we just simply try to simulate in a computer how Carl Djerassi thinks?” And that was really the beginning of a very fruitful collaboration for well over a dozen years in which a lot of other people were involved—Tom Rind-fleisch, Bruce Buchanan, and others. And we published a lot of papers in which we did try to simulate a chemist's thinking in computer-intelligible language. Note that was just the time when other chemists were working on simulating synthetic strategies. We did just the opposite. We talked about how one establishes structure rather than how one synthesizes it. That was unique at that time in the chemical field. What was most interesting, it stimulated us to do a lot of chemical research to fill gaps, intuitive gaps, in our own thinking, which the computer picked up because the computer program wasn't that intuitive yet. And that was really quite interesting, because chemists don't really wonder how they are thinking, they just do it. That really taught us an element of intellectual rigor. And it was a wonderful collaboration of people in medicine and computer science and chemistry. That was a large part of what at that time was called the DENDRAL program, which led to a number of other important algorithms and software projects that were eventually even commercialized. Lederberg has maintained an active laboratory to this day. Josh's contributions included very practical insights, such as designing a highly system for computing the of molecular whose are precisely from mass As the DENDRAL and made modeling the thought processes of chemists working to molecular structures, Josh's interests to the of computer applications. The of computer systems in the and the of computer led Lederberg to of scientists, and not just computer scientists, on research by of these new The resource that he in the early many systems that were the of artificial intelligence research for years to Comments by Former of and Director, Medical Stanford University: one of the most important of Josh's many contributions to medical informatics was his use of and help scientific and collaboration. I came to Stanford in to the DENDRAL At that time there was already a computer resource called ACME that Josh, Ed Feigenbaum, and had in the This resource was the use of computers for in biomedicine and for the of software and information among the and This system was for its It had a very to a system and an that in the and of the that were part of the ACME a after I came to a group of led by Josh Lederberg, the ideas from ACME and DENDRAL in the form of a to the called two ideas at the The first was to a national of artificial intelligence in medicine application and the was to using that was just then by the in the form of the I have to you that the of this was very in of the at It took a and a with and two very long and for us to get for this at the of we did get for and the of a of projects at and a was the first research resource on the In we were number among a of on the in that for about years and was the for more than 20 projects that were the in that the work was the of of but Josh's was in the of the Josh as a as a of as a of that and as a and was Josh wrote a very important essay in that these ideas. It was and the of The New I'd like to a brief from this In it he discussed how of with tools would the of both in time and space, and how this the of in the and use of and scientific in many As I the not how much we have made in the use of but it is with the form of the that have the science is Joshua Lederberg the Morris Collen Award at the in Josh Stanford in to of The University in New the of one of the research he to explore the synthesis of computing and tools with scientific research on many and to serve as a for young in the field of medical informatics. Comments by Edward MD, PhD, Former of SUMEX-AIM, and Professor of and of Computer Science, Stanford University: When I first came to Stanford in the early I was of Josh Lederberg's there. I came with an interest in biomedicine and computer science and so was to such as Josh, Ed Feigenbaum, and Bruce who had the DENDRAL at that Josh, as principal investigator on the new was of having a on the not only because of his work on DENDRAL but also because he a kind of scientific from which I as a young a great I would that Josh an environment in which I was taught to computer science as science, and not simply the of The scientific to one to be that the can the is to and there is an on were in the environment and the in which I computer science because of the of people like Josh. I was very of Josh's even I did not work with him It was He taught me about the of collaboration among scientists of and their to together to new and ideas that are even than the of their He me that there are still In of his in molecular biology and he was contributions in computer science. He was creating an environment in which great computer science work could be done and was also with the and beginning to how they science in the I a mind in and I in him an interest in all things intellectual and an to in very There was much to in Josh Lederberg and his After he moved to Josh to have a at Stanford on our computing environment and on the scientific that we to He was an to the even after his as well as on the He has been a of personal for is available from Josh, and I have found that I can for him for just the that can help me make a He has an for years in and that are to information I don't who is more at using for it with and coming up with ideas for how a environment to and other Josh continues to be a in that area. this Josh Lederberg a and of computing and to his work and to his at the national and The informatics him a great Josh was highly in the University its in the new era of biological science, research, and the of He became of in and to his as a His insights have been as he as an to and a of to his and He has been active in applying scientific to the of research, to public and to As was he has hard at the public and about the of biological and warfare and on and Josh has his active research laboratory at working on the and of on the computer modeling of scientific and on exobiology and the search for the origins of A of the of Joshua Lederberg has been by the Library in their in The is and Josh's papers as a to the history of science. Josh's career in medical informatics, this is available on the Josh's work in informatics is a and he continues to for the field. Comments from an history with Joshua Lederberg, PhD, Former of DENDRAL, and SUMEX-AIM, The University: I'd like to have my name Lederberg's is that really only when they can the and some time in the real the of the is what determine out there. As long as we have to by to be evolving in a very cumbersome and It is with and that the American College of Medical Informatics Joshua Lederberg as of the Morris F. Collen Award. The the of and in the of this award and the also to and the American for for to from their history of Dr. Lederberg, of which are available on the at

Discovery of domain principles has been a major long-term goal for scientists. This paper presents a new system named DOMRUL for learning such principles in the form of rules. A distinctive feature of the system is the integration of the certainty factor (CF) model and a neural network. These two elements complement each other. The CF model offers the neural network better semantics and generalization advantage, and the neural network overcomes possible limitations such as inaccuracies and overcounting of evidence associated with certainty factors. It is a major contribution of this paper to show mathematically the quantizability nature of the CFNet since previously the quantizability of the CF model was demonstrated only empirically. The rule discovery system can be applied to any domain without restriction on both the rule number and rule size. In a hypothetical domain, DOMRUL discovered complex domain rules at a considerably higher accuracy than a commonly used rule-learning program C4.5 in both normal and noisy conditions. The scalability in a large domain is also shown. On a real data set concerning promoters prediction in molecular biology, DOMRUL learned rules with more complete semantics than C4.5.

Computer-based systems that support health care require large controlled terminologies to manage names and meanings of data elements. These terminologies are not static, because change in health care is inevitable. To share data and applications in health care, we need standards not only for terminologies and concept representation, but also for representing change. To develop a principled approach to managing change, we analyze the requirements of controlled medical terminologies and consider features that frame knowledge-representation systems have to offer. Based on our analysis, we present a concept model, a set of change operations, and a change-documentation model that may be appropriate for controlled terminologies in health care. We are currently implementing our modeling approach within a computational architecture.

The manner in which a knowledge-acquisition tool displays the contents of a knowledge base affects the way users interact with the system. Previous tools have incorporated semantics that allow knowledge to be edited in terms of either the structural representation of the knowledge or the problem-solving method in which that knowledge is ultimately used. A more effective paradigm may be to use the semantics of the application domain itself to govern access to an expert system's knowledge base. This approach has been explored in a program called OPAL, which allows medical specialists working alone to enter and review cancer treatment plans for use by an expert system called ONCOCIN. Knowledge-acquisition tools based on strong domain models should be useful in application areas whose structure is well understood and for which there is a need for repetitive knowledge entry.

The InterMed Collaboratory involves five medical institutions (Stanford University, Columbia University, Brigham and Women's Hospital, Massachusetts General Hospital, and McGill University) whose mandate has been to join in the development of shared infrastructural software, tools, and system components that will facilitate and support the development of diverse, institution-specific applications. Collaboration among geographically distributed organizations with different goals and cultures provides significant challenges. One experimental question, underlying all that InterMed has set out to achieve, is whether modern communication technologies can effectively bridge such cultural and geographical gaps, allowing the development of shared visions and cooperative activities so that the end results are greater than any one group could have accomplished on its own. In this paper we summarize the InterMed philosophy and mission, describe our progress over 3 years of collaborative activities, and present study results regarding the nature of the evolving collaborative processes, the perceptions of the participants regarding those processes, and the role that telephone conference calls have played in furthering project goals. Both informal introspection and more formal evaluative work, in which project participants became subjects of study by our evaluation experts from McGill, helped to shift our activities from relatively unfocused to more focused efforts while allowing us to understand the facilitating roles that communications technologies could play in our activities. Our experience and study results suggest that occasional face-to-face meetings are crucial precursors to the effective use of distance communications technologies; that conference calls play an important role in both task-related activities and executive (project management) activities, especially when clarifications are required; and that collaborative productivity is highly dependent upon the gradual development of a shared commitment to a well-defined task that leverages the varying expertise of both local and distant colleagues in the creation of tools of broad utility across the participating sites.

The approach taken by the Unified Medical Language System (UMLS), in which disparate terminology systems are integrated, has allowed construction of an electronic thesaurus (the Metathesaurus) that avoids imposing any restrictions upon the content, structure, or semantics of the source terminologies. As such, the UMLS has served as a unifying paradigm by providing appropriate links among equivalent entities that are used in different contexts or for different purposes. It accordingly provides a vehicle through which possibly orthogonal semantic models can co-exist within a single framework. This framework provides a model for the collaborative evolution of biomedical terminology and allows a synergistic relationship between the UMLS and its source terminology systems.

The authors describe a framework, based on the Ogden-Richards semiotic triangle, for understanding the relationship between the Unified Medical Language System (UMLS) and the source terminologies from which the UMLS derives its content. They pay particular attention to UMLS's Concept Unique Identifier (CUI) and the sense of "meaning" it represents as contrasted with the sense of "meaning" represented by the source terminologies. The CUI takes on emergent meaning through linkage to terms in different terminology systems. In some cases, a CUI's emergent meaning can differ significantly from the original sources' intended meanings of terms linked by that CUI. Identification of these different senses of meaning within the UMLS is consistent with historical themes of semantic interpretation of language. Examination of the UMLS within such a historical framework makes it possible to better understand the strengths and limitations of the UMLS approach for integrating disparate terminologic systems and to provide a model, or theoretic foundation, for evaluating the UMLS as a Possible World--that is, as a mathematical formalism that represents propositions about some perspective or interpretation of the physical world.

OBJECTIVE: To allow exchange of clinical practice guidelines among institutions and computer-based applications. DESIGN: The GuideLine Interchange Format (GLIF) specification consists of GLIF model and the GLIF syntax. The GLIF model is an object-oriented representation that consists of a set of classes for guideline entities, attributes for those classes, and data types for the attribute values. The GLIF syntax specifies the format of the test file that contains the encoding. METHODS: Researchers from the InterMed Collaboratory at Columbia University, Harvard University (Brigham and Women's Hospital and Massachusetts General Hospital), and Stanford University analyzed four existing guideline systems to derive a set of requirements for guideline representation. The GLIF specification is a consensus representation developed through a brainstorming process. Four clinical guidelines were encoded in GLIF to assess its expressivity and to study the variability that occurs when two people from different sites encode the same guideline. RESULTS: The encoders reported that GLIF was adequately expressive. A comparison of the encodings revealed substantial variability. CONCLUSION: GLIF was sufficient to model the guidelines for the four conditions that were examined. GLIF needs improvement in standard representation of medical concepts, criterion logic, temporal information, and uncertainty.

OBJECTIVE: An evaluation of the cognitive processes used in the translation of a clinical guideline from text into an encoded form so that it can be shared among medical institutions. DESIGN: A comparative study at three sites regarding the generation of individual and collaborative representations of a guideline for the management of encephalopathy using the GuideLine Interchange Format (GLIF) developed by members of the InterMed Collaboratory. MEASUREMENTS: Using theories and methods of cognitive science, the study involves a detailed analysis of the cognitive processes used in generating representations in GLIF. The resulting process-outcome measures are used to compare subjects with various types of computer science or clinical expertise and from different institutions. RESULTS: Consistent with prior studies of text comprehension and expertise, the variability in strategies was found to be dependent on the degree of prior experience and knowledge of the domain. Differing both in content and structure, the representations developed by physicians were found to have additional information and organization not explicitly stated in the guidelines, reflecting the physicians' understanding of the underlying pathophysiology. The computer scientists developed more literal representations of the guidelines; addition were mostly limited to specifications mandated by the logic of GLIF itself. Collaboration between physicians and computer scientists resulted in consistent representations that were more than the sum of the separate parts, in that both domain-specific knowledge of medicine and generic knowledge of guideline structure were seamlessly integrated. CONCLUSION: Because of the variable construction of guideline representations, understanding the processes and limitations involved in their generation is important in developing strategies to construct shared representations that are both accurate and efficient. The encoded guidelines developed by teams that include both clinicians and experts in computer-based representations are preferable to those developed by individuals of either type working alone.

OBJECTIVE: To explore different user-interface designs for structured progress note entry, with a long-term goal of developing design guidelines for user interfaces where users select items from large medical vocabularies. DESIGN: The authors created eight different prototypes of a pen-based progress-note-writing system called PEN-Ivory. Each prototype allows physicians to write patient progress notes using simple pen-based gestures such as circle, line-out, and scratch-out. The result of an interaction with PEN-Ivory is a progress note in English prose. The eight prototypes were designed in a principled way, so that they differ from one another in just one of three different user-interface characteristics. MEASUREMENTS: Five of the eight prototypes were tested by measuring the time it took 15 users, each using a distinct prototype, to document three patient cases consisting of a total of 63 medical findings. RESULTS: The prototype that allowed the fastest data entry had the following three user-interface characteristics: it used a paging rather than a scrolling form, it used a fixed palette of modifiers rather than a dynamic "pop-up" palette, and it made available all findings from the controlled vocabulary at once rather than displaying only a subset of findings generated by analyzing the patient's problem list. CONCLUSION: Even simple design changes to a user interface can make dramatic differences in user performance. The authors discuss possible influences on performance, such as positional constancy, user uncertainty and system anticipation, that may contribute significantly to the effectiveness of systems that display menus of items from large controlled vocabularies of medicine.

Some observers feel that the federal government should play a more active leadership role in educating the medical community and in coordinating and encouraging a more rapid and effective implementation of clinically relevant applications of wide-area networking. Other people argue that the private sector is recognizing the importance of these issues and will, when the market demands it, adopt and enhance the telecommunications systems that are needed to produce effective uses of the National Information Infrastructure (NII) by the healthcare community. This debate identifies five areas for possible government involvement: convening groups for the development of standards; providing funding for research and development; ensuring the equitable distribution of resources, particularly to places and people considered by private enterprise to provide low opportunities for profit; protecting rights of privacy, intellectual property, and security; and overcoming the jurisdictional barriers to cooperation, particularly when states offer conflicting regulations. Arguments against government involvement include the likely emergence of an adequate infrastructure under free market forces, the often stifling effect of regulation, and the need to avoid a common-and-control mentality in an infrastructure that is best promoted collaboratively.

Edward H. Shortliffe, MD, PhD; Dehumanization of Patient Care—Are Computers the Problem or the Solution?, Journal of the American Medical Informatics Associatio

The manner in which a knowledge-acquisition tool displays the contents of a knowledge base affects the way users interact with the system. Previous tools have incorporated semantics that allow knowledge to be edited in terms of either the structural representation of the knowledge or the problem-solving method in which that knowledge is ultimately used. A more effective paradigm may be to use the semantics of the application domain itself to govern access to an expert system's knowledge base. This approach has been explored in a program called OPAL, which allows medical specialists working alone to enter and review cancer treatment plans for use by an expert system called ONCOCIN. Knowledge-acquisition tools based on strong domain models should be useful in application areas whose structure is well understood and for which there is a need for repetitive knowledge entry.