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Blue Ribbon Panel on Academic 

Rheumatology 

Final Report: November 10, 2012 

The challenges and the opportunities facing academic rheumatology are multidimensional and complex. As the 

essential pipeline for the development of rheumatology practitioners in the community, issues which affect the 

vitality of academic rheumatology have broad implications on the viability of the greater profession. This 

report includes a summary of the critical issues along with specific recommendations to address these issues 

over the short and long term. 

0

Final Report: ACR Blue Ribbon Panel on Academic Rheumatology 

Table of Contents 

1. Executive Summary…………………………………………………. 2 

2. Introduction…………………………………………………………….. 5 

2.1. Background……………………………………….... 5 

2.2. Scope of Work…………………………………….. 7 

2.3. Goals ………………………………………………….. 7 

2.4. Timeline ……………………………………………… 7 

2.5. Methodology ……………………………………… 9 

2.6. Glossary ………………………………………………. 13 

3. Critical Issues and Recommendations …………………….. 15 

3.1. Crisis in Funding …………………………………….. 16 

3.2. Redefining Scope ………………………………...… 27 

3.3. Research Consortia ………………………………. 33 

3.4. New Technologies…………………………………. 39 

3.5. Clinical Data Infrastructure…………………….. 47 

3.6. Regulatory Burdens……………………………….. 51 

3.7. Workforce Development……………………….. 58 

3.8. Career Development…………………………….. 65 

3.9. Leadership Development……………………….. 71 

3.10. Demonstrating Value…………………………. 76 

4. Summary of Recommendations ………………………………. 83 

5. Additional Areas to Consider ……………………………………. 88 

6. Next Steps ……………………………………………………………….. 89 

7. Acknowledgments…………………………………………………….. 91 

8. References………………………………………………………………… 93 

November 2012 1


1. Executive Summary 

The challenges and the opportunities that confront academic rheumatology in 2012 are multidimensional 

and complex. Academic units strive to nurture and balance their multiple missions of research, clinical 

care and teaching in a rapidly changing environment in which the economic viability of rheumatology is far 

from secure. As the essential pipeline for the development of rheumatology practitioners in the 

community, issues which affect the vitality of academic rheumatology have broad implications on the 

viability of the greater profession. The availability of a sufficiently robust academic workforce for the 

future, especially at the leadership level, is uncertain. At the same time the potential for transformative 

basic discoveries and clinical advances that lead to better prevention, treatment, and even cure of adult 

and pediatric rheumatic diseases has never been greater. 

Recognizing these challenges and opportunities, the College had the foresight to convene a timely review 

of the state of academic rheumatology in the US and charged this Blue Ribbon Panel with making 

recommendations to address the key issues. 

As a result of the process undertaken, the panel envisages a new future role for the College as a much 

closer partner of academic divisions of rheumatology. This partnership will encompass the development 

of tools that academic units can use to demonstrate their economic value, assess and strengthen their 

financial health, improve and expand training of both rheumatology fellows and mid-level providers for all 

of the career opportunities within the field, and enhance quality of patient care. The partnership will 

involve a sharper focus on advocacy related to issues critical to the future well-being of our academic 

rheumatology divisions. It will also include significant investments by the College and the Foundation in 

rheumatology career development, ongoing analyses of the effectiveness of research funding support for 

academic rheumatology units, and a comprehensive program of leadership development. 

While the charge to the task force was to focus on academic rheumatology, the panel quickly recognized 

that the historical lines dividing academics and various types of private practices have become increasingly 

blurred. In an effort to be comprehensive and include recommendations to appropriately train physicians 

and health professionals for a variety of careers, including community practice, education, research and 

industry, a comprehensive review was conducted and broad-reaching recommendations are therefore 

included within this report. It is anticipated that many of the recommendations contained herein will not 

be exclusively related to academic units; rather the expectation is that they will benefit the entire 

rheumatology community. 

This report contains a summary of the critical issues identified within academic rheumatology, across the 

domains of training, practice and research. Also included are specific recommendations to address these 

November 2012 2


issues over the short and long term. A brief summary of these issues and recommendations is included 

below: 

1. Addressing the funding crisis for rheumatic disease research and training. This is especially 

challenging without sufficient data to fully understand scope, trends and impact of historical 

underfunding and the diffusion of support for rheumatic disease and arthritis research owing to 

its distribution across multiple NIH centers and institutes. 

2. Redefining the scope of rheumatology. With an ever changing patient care landscape, 

rheumatology is extending its reach throughout both clinical immunology and musculoskeletal 

medicine, as well as other potential emerging clinical care and research domains. 

3. Developing research infrastructure and consortia. There is a great need within rheumatology to 

support large-scale research projects, while including a broader array of stakeholders. 

4. Expanding our clinical data infrastructure. This issue examines how clinical data infrastructure 

might be expanded within rheumatology while integrating cross-disciplinary expertise. 

5. Addressing regulatory burdens. Burdens within both the clinical and scientific enterprise have a 

negative impact on our productivity as a specialty, from house officer duty hours to IRB 

congestion and duplication and burdensome reporting responsibilities. 

6. Development and adoption of new technologies. It is imperative that available opportunities to 

increase new value-driven cost effective approaches to patient care be seized, including 

development and adoption of new technologies, diagnostics and therapeutics. 

7. Workforce development and maintenance. This is necessary across all domains (training, 

practice and research) in order to develop an adequate supply of providers to meet current and 

future demands of patient care, research and education. This topic includes expansion of the 

quality and quantity of the physician fellowship pool, as well as the efficient incorporation of 

health professionals and doctoral level faculty into academic units. 

8. Career development and faculty retention within the College and within academic centers, 

including the use of new mechanisms that can foster academic careers and overcome bottlenecks 

at both early and mid-level career development stages. 

9. Developing future leaders within the College, the global research community, and academic 

centers is essential to ensure that there is a robust pool of leaders to serve as future division 

chiefs, center directors, fellowship directors, clinical program directors and College leaders. 

10. Formally demonstrating the value (financial, scientific, clinical and educational) of academic 

rheumatology among departments of internal medicine and pediatrics, academic medical centers 

and the general public. This includes increasing awareness of the contributions of academic 

November 2012 3


rheumatology to the development of new scientific knowledge, new therapeutics, and new 

approaches to clinical care and education. 

The panel is grateful for the opportunity to present these issues and ideas to you, the leadership of the 

College, and feels confident these recommendations will help shape the future of rheumatology in the US. 

Thank you for your careful review and consideration of this report. 

November 2012 4


2. Introduction 

2.1. Background 

In 1997 the ACR convened its first panel charged with assessing the state of academic rheumatology and 

recommending actions the College could take to strengthen academic rheumatology. This panel, led by 

former ACR President Dr. Eng Tan, presented its report to the ACR Board in February 1998. At that time, 

academic rheumatology research was dominated by basic science investigation, and many of these 

researchers were thought to be drifting away from participation in the ACR annual meeting. Recruitment of 

new fellows into rheumatology training programs had lagged through the mid-1990’s, with more than 1/3 of 

the available positions unfilled. The majority of fellows and applicants at that time were foreign medical 

graduates, and interest in a rheumatology career had waned among US medical graduates. Recent high profile 

publications had questioned the need for an expansion of the number of clinical rheumatologists to care for 

individuals with rheumatic diseases. The use of biologic therapeutics was just getting started, and the full 

impact of this new class of medications on patients with rheumatic diseases and the clinical practice of 

rheumatology was not yet apparent. The programs of the Foundation were small in scale and scope, and 

mechanisms for major infusions of funds into the Foundation did not yet exist. Most ARHP members were 

physical or occupational therapists, while involvement of nurse practitioners and physician assistants in the 

clinical practice of rheumatology was a rarity. 

The College has grown enormously since 1998, and in many respects the 1998 panel’s recommendations 

pointed the way to this growth. Their report was divided into 4 sections: research, training and education, 

patient care, and partnerships with the pharmaceutical industry. Some important outcomes of key 

recommendations include the following: 

 

 

Recommendations to strengthen the Foundation and to develop a mechanism for “block grants” from 

industry became the basis for the development of the Industry Roundtable. The IRT became the key 

mechanism for the exponential growth of funding and programs from 2000 on. The Foundation has 

played critical roles in funding training of more rheumatology fellows and supporting career 

development of young rheumatology researchers, including clinical and translational investigators. 

The importance and timeliness of the Foundation’s expansion was heightened by the concurrent 

contraction of other funding mechanisms for rheumatology career development. The growth of the 

Foundation helped to ensure that once again most available training slots were filled from a betterqualified 

applicant pool with an expanded representation of US medical graduates. 

The panel recommendation to devise a mechanism for support and cultivation of rheumatology 

clinician scholar educators led directly to the development of a new Clinician Scholar Educator Award, 

which has contributed to career development and retention of an important subset of academic 

November 2012 5


 

 

rheumatology faculty. Fifty-five notable scholars across the US have received support from this 

program since its inception in 2000. 

The panel recommendation to re-structure the annual meeting into distinct modules that would 

appeal to either researchers or clinicians, while not fully implemented, led to the creation of the highly 

successful basic and then clinical research conferences that precede the annual meeting. These 

conferences have helped to augment participation of researchers in the annual meeting, which has 

grown considerably over the past 14 years. In addition, the meeting has evolved over time to include 

specialized tracks for clinicians, educators, researchers, etc. 

The panel recommended development of training standards for fellowship programs, and this has 

been addressed by creation of a core curriculum and an in-training examination. Much more support 

is now available for fellows to participate in professional meetings, and these programs have become a 

funding priority for the College. 

The report also anticipated expansion of translational research, the need for specialized training in clinical 

research, development of disease-specific databases, new NIH grant mechanisms that allowed co-principal 

investigators, and expansion of research in pediatric rheumatology. A recommendation for increased ties to 

professional organizations in orthopedics and rehabilitation medicine came to modest fruition in the College’s 

participation in activities of the US Bone and Joint Initiative, including participation of several ACR members in 

the Young Investigators Workshop, a valuable training program for early career researchers. In addition, the 

College recently joined the Council for Medical Specialty Societies, which presents new opportunities to work 

with other professional medical organizations. 

Some panel recommendations were not implemented. These included transfer of Arthritis and Rheumatism 

to the Foundation and a major expansion of joint programs with the Arthritis Foundation to support 

rheumatology research. 

Notably, other topics that have become important to academic rheumatology in recent years were not 

considered by the 1997-98 panel, including the changing spectrum of diseases in academic rheumatology 

practice, the major impact of regulatory expansion, use of advanced imaging techniques in the rheumatology 

clinic, the expanding roles of nurse practitioners and physician assistants in rheumatology patient care, and 

the impact of genetics, systems biology and other new technologies on the rheumatology research agenda. 

In summary, the recommendations of the 1998 panel were followed, in several key areas, by subsequent bold 

initiatives by the College that have been remarkably successful. Since then, new sets of challenges and 

opportunities have arisen that again require fresh analysis and innovative approaches. 

In response to the need to review the current state of academic rheumatology, the ACR President convened a 

second Blue Ribbon Panel in December 2011, reporting directly to the Executive Committee. This panel was 

charged with assessing the current state of academic rheumatology in the US and making SMART (Specific, 

November 2012 6


Measurable, Attainable, Relevant and Timely) recommendations to ensure its success in the future. This panel 

was created based on the model established by ACR past President Dr. William Koopman, who convened the 

first such panel in 1997. 

2.2. Scope of Work 

With the agreement of the Executive Committee, the panel defined the scope of work for this activity around 

three priority domains: training, practice and research. After more than a decade of progress, it was felt to be 

critical to carefully evaluate each of these domains. Notably, practice issues were perceived to be increasingly 

important to consider as clinical care models continue to evolve, the impact of healthcare legislation emerges 

and academic divisions rely more heavily on clinical income relative to research grants and hard money 

sources. In addition, funding sources for all of the activities of rheumatology divisions across the country are 

under increasing pressures. This situation has greatly impacted our profession in many ways, and in order to 

plan for the future, it was considered essential by the panel to collect additional real-time data on the effects 

of the changing landscape that would allow the group to make proactive rather than reactive 

recommendations. While the primary focus of this report is academic rheumatology, the panel has included 

some recommendations which are purposefully broad-reaching. It is anticipated that many of the 

recommendations contained herein will not be exclusive to academic units, and will benefit the entire 

rheumatology community. 

2.3. Goals 

The primary goal of the panel was to deliver a report containing a set of SMART (Specific, Measurable, 

Attainable, Relevant and Timely) recommendations designed to help ensure the future success of academic 

rheumatology. Inherently, many of the recommendations may benefit the entire rheumatology community. 

Secondary goals included establishing improved procedures for data collection and analysis, assessing staff 

and volunteer needs in the areas examined, ensuring that the ACR itself follows best practices in its activities, 

and programs relevant to academic rheumatology, and encouraging member participation and engagement in 

the work of this panel. 

2.4. Timeline 

The work of this panel was completed over a period of 10 months, from January through November 2012. The 

panel was assembled between December 2011 and January 2012, with a primary goal of including members 

from a wide variety of backgrounds within the organization. The panel also included representatives from key 

committees. The first conference call was held on January 20, 2012. The data acquisition and analysis process 

was completed between January and March, with data discs distributed to the panel members in advance of a 

comprehensive webinar held on March 5 during which the group further defined the scope of work for the 

panel and conducted an interactive review of the available resources. Analyses of the strengths, weaknesses, 

November 2012 7


opportunities and threats within each domain (training, practice and research) were then conducted between 

March and April, and these SWOT analyses were presented and discussed at the panel’s first face-to-face 

meeting on April 27 in Chicago. From there, critical issues were identified and comments were sought from 

the membership between May and July. Over the summer (June through August), the panel drafted 

specification reports for each of the top ten issues, with specific recommendations created for each issue. The 

specification reports and recommendations were discussed at the second face-to-face meeting on August 3. 

The co-chairs then drafted the final report which was shared with the panel and refined during September and 

October. The final report will be shared with the ACR Board of Directors, along with a presentation of the 

recommended actions at the Board of Directors Meeting in conjunction with the Annual Meeting, November 

10, 2012. A detailed project timeline is included below. 

Detailed Project Timeline: 2012 

Jan 9 

Jan 20 

Wk Mar 5 

Wk Mar 14 

Mar – Apr 15 

Wk Apr 9 

Apr 27 

May 18 

May 24 

Wk June 25 

Jun 25 – Jul 20 

July 16 

Wk July 20 

August 3 

Wk Sep 10 

Wk Oct 1 

Wk Oct 22 

Confirmation of participants; scheduling of first group conference call 

Conference call to discuss charge and data collection/analysis process 

Conference call to review results of assignments; define domains 

Sub-group conference calls to discuss SWOT analysis areas to address 

Sub-groups complete SWOT analysis tables per assignments 

Sub-group conference calls to finalize SWOT analysis tables 

Face-to-face meeting to review SWOT analyses in each domain 

Critical issues presented to ACR Board of Directors 

Conference call to finalize list of critical issues 

Critical issues posted online for comment from membership 

New discs with additional background data provided 

Domain conference calls to discuss potential solutions to top ten issues 

Groups complete specification reports for assigned critical issues 

Comments from membership on critical issues due; distributed to panel 

Conference call to prepare presentations for August meeting 

Face-to-face meeting to present and discuss recommendations 

Panel members review draft of final report 

Panel members review final draft of final report 

Conference call to discuss presentation of recommendations 

November 2012 8


2.5. Methodology 

In order to develop a set of SMART recommendations, the panel engaged in strategic planning exercises and 

implemented methodology commonly used in strategic planning in order to: 1) analyze the current state of 

academic rheumatology in the US; 2) set strategic directions and goals to ensure its success in the future; and 

3) develop an action plan with projected benchmarks and outcomes to ensure that these goals are met and to 

maintain accountability. 

The panel was carefully constructed to include representatives from a variety of constituent groups within the 

academic rheumatology community, including academic clinical practice, pediatrics, basic science, clinical 

investigation, health information technology, training programs, and ARHP members. The nature of the 

process was highly collaborative with input solicited from a variety of ACR committees as well as the 

membership at large. Each member was highly engaged in the work of the panel, taking leadership roles at 

various points throughout the process. 

The work of the panel was extensive. Overall, the panel engaged in over 20 conference calls including full 

panel, domain sub-group and issue team calls. In addition, the group convened 2 face-to-face meetings with 

participation of each panel member at one or both meetings. Notes from each call and meeting were carefully 

recorded and distributed to members of the panel for further review and comment after each meeting to 

ensure quality control of meeting outcomes. Over 200 reference materials were reviewed by the group in 

order to generate the 28 pages of SWOT analyses. From these analyses, the group identified the top ten issues 

most critical to academic rheumatology. These issues were shared with the membership online along with a 

call for comments. This call produced 12 pages of comments (N=16) which were reviewed by the panel, and 

addressed in their detailed specification reports written to address each of the issues. In preparation for this 

final report, 68 pages of specification reports were prepared and reviewed to consider in depth the details and 

potential solutions around each of the top ten issues. 

2.5.1. Data Collection 

A period of data acquisition took place between January and March 2012, including data requests from 

internal committees, councils and departments, as well as external groups (both private and public funding 

agencies) named below. Additional data was acquired as it became available during the remainder of the 

process. Of the sixteen external organizations the panel reached out to, eleven responded favorably and 

provided the requested data. This represents a 69% response rate, which the panel viewed as very good. 

November 2012 9


The following organizations, committees and councils were invited to provide data and input into this 

important process (those marked with an asterisk contributed requested information or data): 

1. Alliance for Lupus Research* 

2. American Autoimmune Related Diseases 

Association* 

3. Arthritis Foundation * 

4. Arthritis National Research Foundation* 

5. Autoimmunity Centers of Excellence* 

6. Crohn's and Colitis Foundation* 

7. Department of Defense 

8. Immune Tolerance Network 

9. Lupus Foundation of America* 

10. Lupus Research Institute 

11. National Institutes of Health 

12. National Psoriasis Foundation* 

13. Patient-Centered Outcomes Research 

Institute 

14. Scleroderma Foundation* 

15. Sjogren’s Syndrome Foundation * 

16. Vasculitis Foundation* 

17. ACR Committee on Education* 

18. ACR Committee on Rheumatologic Care* 

19. ACR Government Affairs Committee* 

20. ACR Quality of Care Committee * 

During the panel’s March 5 webinar, the panel reviewed the ACR’s current functions, projects, programs and 

activities, as well as available resources and data, in order to establish a baseline level of knowledge amongst 

the group on current activities. The three priority domains were also identified and panel member 

assignments shared with the group. Next, each of the domain sub-groups held conference calls to conduct 

SWOT analyses in each domain. 

2.5.2. Data Analysis 

The panel conducted a comprehensive scan of the academic rheumatology environment in the US, across all 

three domains (training, practice and research). After careful consideration and discussion of the strengths, 

weaknesses, opportunities and threats (thus the SWOT acronym for this activity) regarding the state of 

academic rheumatology in the US, the panel conducted a detailed analysis to look at the various driving forces 

in the environment, for example, increasing competition, changing demographics, etc. 

Within each domain, specific areas to address were identified and then run through the analysis. The areas 

identified included the trainee pipeline, support for junior faculty, the role of committees and councils, 

strategic partnerships with external organizations, efficacy and outcomes of College and Foundation 

programs, funding availability and trends, the role of registries and research consortia, infrastructure support, 

recruitment, non-physician workforce development, scope of practice, demonstrating value, clinical income, 

practice efficiency, and leadership development. 

Panel members reviewed hundreds of reference materials in order to generate 28 pages of SWOT analyses 

written between March 15 and April 15. The completed analyses were presented and discussed at the panel’s 

first face-to-face meeting, held April 27 in conjunction with the State of the Art Clinical Symposium. At this 

November 2012 10


meeting, the panel carefully reviewed the analyses from each domain and began to discuss some of the 

common themes that emerged from each of the groups (training, practice and research). 

2.5.3. Identification of Critical Issues 

In order to further evaluate the SWOT analyses during the April 27 meeting, and begin to identify the issues 

most critical to academic rheumatology, members of the panel were assigned to three random think-tank 

groups to brainstorm independently what issues and themes from the analyses were the most critical and 

highest priority to be addressed by this group. 

After the brainstorming session, each of the groups presented their ‘top ten’ issues to the entire panel. A total 

of 18 unique issues were identified by the three groups. Each issue was carefully considered and discussed by 

the panel, with great effort made to prioritize the most critical issues, as well as consolidate several similar 

and overlapping issues, resulting in a final list of the top ten issues most critical to academic rheumatology. 

After careful review of the list by the members of the panel with feedback and recommended language 

changes to descriptions, the list was shared with the ACR leadership and membership with a call to submit 

comments. Comments were due July 16, 2012 and were shared with the members of the panel. The call for 

comments produced 12 pages of comments (N=16) which were reviewed by the panel, and addressed in their 

discussion of the potential solutions. 

2.5.4. Potential Solutions 

In order to prepare the panel to complete their specification reports, a series of conference calls and many e- 

mail exchanges were held with the panel Co-Chairs and each of the domain groups (training, practice and 

research). The purpose of these calls was to 1) review the resources available on the data discs relevant to 

each issue and solution; 2) define the format for the recommended solutions, goals and objectives to be 

contained in the specification reports; and 3) discuss potential solutions to the issues identified within each 

domain. 

2.5.5. Specification Reports 

In order to begin to craft specific conclusions about what must be done to address the major issues and 

opportunities facing the organization, the panel first needed to identify the strategic goals to correspond with 

each of the top ten issues. 

To accomplish this task, ten panel members were appointed as team leaders, each responsible for writing 

specification reports for one of the ten critical issues detailing the background of the issue, the goal or 

objective that would address the issue, a statement of the strategy or tactics to accomplish the goal, and a 

November 2012 11


summary of the resources that may be required to achieve the goal. Each panel member participated in 2-3 

issue groups, either as a leader or member. In order to be effective, these goals were designed and worded as 

much as possible to be specific, measurable, attainable to those working to achieve the goals, realistic, and 

timely (thus the acronym SMART). 

The panel reviewed over 200 reference materials, including comments from the membership and input from 

several committees and councils, in order to write informed reports. In total, 68 pages of specification reports 

were prepared and reviewed by the panel. These reports carefully lay out how the strategic goals 

recommended by the panel may be accomplished. Each objective is associated with methods needed to reach 

the objective. The reports also specify resources and responsibilities for each objective, noting what 

organizational resources may be required, and/or who would be responsible for executing the strategies to 

achieve the goals. 

The final report, encompassing all of the background and issues from the individual components prepared 

during the 10 month efforts by the panel, was initially constructed by ACR staff member Mary Wheatley and 

the two Co-Chairs, Drs. Holers and Fox, who also wrote and reviewed additional background and linking 

sections for the document. After a final review by the entire Panel, this current version of the document was 

completed by the three individuals and approved by the Co-Chairs for submission to the Executive Committee. 

Notably, because the panel understands that individual sections will likely be reviewed by readers outside the 

context of the entire document, there is some duplication, and re-referencing, of background material and 

recommendations where it was thought to be essential for better understanding of the individual issues. In 

addition, the panel recognizes that many of the issues that have been identified are currently being addressed 

within the College; the intent of highlighting these areas, in addition to new recommendations, is to assure 

that the entire College is aware of the importance to academic rheumatology of these ongoing efforts and 

that the programs continue with high priority. 

2.5.6. Recommendations 

In order to carefully evaluate areas of complement and overlap, and develop a final list of recommendations, 

the panel held a face-to-face meeting in Atlanta on August 3 to review their resources, including the 

previously completed environmental scan and SWOT analyses, as well as their recently completed 

specification reports. Each team leader presented their team’s specification report which addressed their 

assigned issue(s), and each recommendation was carefully considered and discussed by the group. The group 

also discussed priorities and timelines for the goals identified in the meeting. The recommendations are 

included in Section 3 and summarized in Section 4 of this report. 

November 2012 12


2.6. Glossary 

Terms and acronyms used in this report are listed below with their definitions, in alphabetical order 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A&R: Arthritis and Rheumatism, one of two 

journals published by the ACR 

AAHC: Association of Academic Health 

Centers 

AAMC: Association of American Medical 

Colleges 

ABIM: American Board of Internal Medicine 

AC&R: Arthritis Care and Research, one of 

two journals published by the ACR. 

ACGME: The Accreditation Council for 

Graduate Medical Education 

ACTS: NIH Arthritis, Connective Tissue and 

Skin Study Section 

AF: Arthritis Foundation 

AMIGO: ACR/CARRA Mentoring Interest 

Group 

APN: Advanced Practice Nurse 

ARHP: Association of Rheumatology Health 

Professionals, a division of the ACR 

CARRA: Childhood Arthritis & 

Rheumatology Research Alliance 

CDC: Centers for Disease Control and 

Prevention 

CJP: ACR Committee on Journal Publications 

CMS: Center for Medicare and Medicaid 

Services 

COE: ACR Committee on Education 

COI: Conflict of interest 

COR: ACR Committee on Research 

CORC: ACR Committee on Rheumatologic 

Care 

COTW: ACR Committee on Training and 

Workforce Issues 

 

 

 

 

 

 

CQM: Clinical quality measures 

CSR: NIH Center for Scientific Review 

CTSA: NIH clinical and translational science 

awards 

DMARD: Disease modifying anti-rheumatic 

drug 

DORTP: Directors of Rheumatology Training 

Programs 

EHR: Electronic Health Records, also 

referred to as EMR: Electronic Medical 

Records 

F grants: NIH fellowship grants (e.g., F32) 

 

 

 

 

 

 

 

 

 

 

 

 

FDA: Food and Drug Administration 

FDP: Federal Demonstration Partnership 

Foundation: Refers to the Rheumatology 

Research Foundation (formerly the 

American College of Rheumatology 

Research and Education Foundation) 

effective November 10, 2012 

GAC: ACR Government Affairs Committee 

HEDIS: The Healthcare Effectiveness Data 

and Information Set 

HIPAA: The Health Insurance Portability and 

Accountability Act 

HP: Health professionals 

IACUC: The Institutional Animal Care and 

Use Committee 

IMG: International Medical Graduate 

IRB: Institutional Review Board 

IRT: Industry Roundtable, now the 

Corporate Roundtable 

K awards: NIH mentored research training 

grant (e.g., K08, K23) 

November 2012 13


 

 

MLP: Mid-level providers such as Nurse 

Practitioners and Physician Assistants 

MSUS: Musculoskeletal ultrasound 

 

 

RA: Rheumatoid Arthritis 

RC-IM: Residency Review Committee for 

Internal Medicine 

 

NAS: New accreditation system 

 

RCR: Rheumatology Clinical Registry 

 

NBME: National Board of Medical 

Examiners 

 

 

REDCap: Research electronic data capture 

RFA: Request for applications 

 

NIAID: National Institute of Allergy and 

Infectious Diseases 

 

RHIT: ACR Committee on Registries and 

Health Information Technology 

 

NIAMS: National Institute of Arthritis and 

Musculoskeletal and Skin Diseases 

 

RISE: Rheumatology Information Systems 

for Effectiveness 

 

 

NIH: National Institutes of Health 

NP: Nurse practitioner 

 

SAC: Rheumatology Research Foundation 

Scientific Advisory Council 

 

NSF: National Science Foundation 

 

SLE: Systemic Lupus Erythematosus 

 

 

OA Initiative: The Osteoarthritis Initiative, a 

multicenter, longitudinal, prospective 

observational study of knee osteoarthritis, 

funded in partnership between the NIH and 

private sources. 

OA: Osteoarthritis 

 

 

 

SMART: Specific, Measurable, Attainable, 

Relevant and Timely 

SSc: Systemic sclerosis, also known as 

scleroderma 

STTR: Small business technology transfer 

grant program through the NIH 

 

OOPD: Office of Orphan Product 

Development 

 

SWOT: Analysis of Strengths, Weaknesses, 

Opportunities and Threats 

 

 

PA: Physician Assistant 

PCORI: Patient Centered Outcomes 

Research Institute 

 

 

T grants: NIH training grant mechanisms 

(e.g., T32) 

TNF: tumor necrosis factor 

 

 

PHS: US Public Health Service 

PIM: Performance improvement module 

 

TR: The Rheumatologist, the ACR's monthly 

magazine 

 

 

PQRS: Physician Quality Reporting System 

PR: Public relations 

 

U grants: NIH research project cooperative 

agreement funding mechanism (e.g., U01) 

 

QOC: ACR Quality of Care Committee 

 

VA: Veteran’s Administration 

 

R grants: NIH research projects grants (e.g., 

R01) 

 

VCRC: Vasculitis Clinical Research 

Consortium 

November 2012 14


3. Critical Issues and Recommendations 

This report focuses on the delineation of these challenges and opportunities, and on recommendations for 

actions to address these issues. The panel believes the College is a healthy and effective organization, and 

is not recommending any major overhauls of current survival and core functions of the College. 

As a result of the process undertaken, the panel envisages a new future role for the College as a true 

partner with divisions of rheumatology. This partnership will encompass the development of tools that 

academic units can use to demonstrate their economic value, assess their financial health, improve and 

expand training of both rheumatology fellows and mid-level providers for all of the career opportunities 

within the field, and enhance quality of patient care. 

The partnership will involve a sharper focus on advocacy related to issues critical to the future well-being 

of our academic rheumatology divisions. It will include an expansion of the investment of both the College 

and the Foundation in rheumatology career development, extending well beyond the level of fellowship 

training to include nurturing of junior faculty and a comprehensive program of leadership development. 

While no major structural changes are recommended, it is expected that two enhancements will be 

required: first, an expansion of the role of the Nominations Committee to include a broadening of 

volunteer recruitment efforts and a proactive program of leadership development and evaluation; and, 

second, creation of a new entity within the College, an association of chiefs of divisions of rheumatology. 

The following sections delineate, issue by issue, the ten salient areas of challenge and opportunity that the 

panel has identified, along with our specific recommendations for action to address each of these issues. 

November 2012 15


3.1. Crisis in funding for rheumatic disease research and research training, in the context of lack of 

sufficient data to fully understand the scope, trends and impact of historical underfunding; diffusion 

across multiple NIH institutes of rheumatic disease and arthritis research funding; and opportunities 

to enhance research support across multiple institutes of the NIH and other agencies and 

foundations, in view of expansion of the clinical scope of rheumatology 

3.1.1. Background and Rationale 

 

 

 

 

There are an increasing number of opportunities for meaningful and innovative research in rheumatic 

diseases. Through substantial effort, the College has defined a broad-reaching research agenda that is 

relevant to the academic rheumatology community 1 . Because of this, problems within academic 

rheumatology are not related to a lack of opportunity for meaningful research but rather to difficulties 

in supporting and maintaining these endeavors in the current and future funding climate. 

There are no study sections in which the majority of reviewers are expert in rheumatic disease 

research, especially in areas of clinical research. In particular, many substantive concerns exist with 

regard to the ability of the ACTS study section 2 , where a large majority of rheumatology translational 

and clinical research is reviewed, to provide a sufficiently informed review in an equitable manner that 

allows the best proposals to achieve funding. Because of this situation, which is longstanding and 

multi-factorial in origin, coupled with the diffusion of areas of rheumatic disease research across many 

other study sections, there is a substantial concern that there are insufficient opportunities for 

rheumatic disease researchers, especially those focused on clinical research, to achieve balanced 

reviews and scoring by fully knowledgeable reviewers. 

Although the majority of rheumatic disease research is funded through NIAMS and NIAID, the scope of 

the disease process in patients encompasses many target organs and pathologic processes, and thus 

reaches across many NIH institutes and a wide variety of research-minded lay organizations. 

The Blue Ribbon Panel has been unable to acquire, despite substantial internal efforts and requests to 

the NIH through open records access mechanisms, data with regard to funding levels for ACR members 

from the NIH inclusive of R, U and other types of competing grant awards. It is also not known what 

has been the impact of new Director’s Office grants on funding of academic rheumatologists, and there 

is no quantitative understanding of the impact of the NIH CTSA funding mechanisms on rheumatic 

disease research. In addition, it is not known what proportion of research within the NIH intramural 

program is focused on rheumatic disease research that is relevant to academic rheumatology. Because 

of this lack of robust data, there is a lack of an understanding of the scope of the funding problem 

within academic rheumatology as it pertains to NIAMS and NIAID, the two primary institutes funding 

rheumatic disease research, and the impact of diffusion across multiple NIH institutes of support for 

research in academic rheumatology units. In addition, it is not clear what proportion of recent trends 

are positive or negative, and to what magnitude. Without acquiring these data in a continuous manner 

November 2012 16


 

to analyze funding trends, it is increasingly difficult to identify and pursue the most relevant and 

impactful approaches to improving the academic rheumatology funding status. 

Several studies have pointed to the impending shortage of clinical rheumatologists based on 

demographics of the current workforce 3,4 (age distribution, gender trends) and impending retirements 

of a large segment of the work force 5 and there are a substantial number of insightful academic 

benchmark data as “snapshots” that have been recently acquired with recommendations for continued 

analysis and specific projects 6,7 . However, many of the recommendations have not yet been acted 

upon, and there is as yet little quantitative understanding of the expected impact over the next decade 

of these demographic factors on the academic rheumatology community. There is also little 

understanding of whether the private practice, clinical care, and research workforce pipelines are 

restricted by the relatively small size of the academic work force. Therefore, there is not a complete 

understanding of what specific actions should be taken to maintain, and to build, the academic training 

environment through which both our 

clinicians and research intensive members 

must be initially recruited and then pass 

through to their next career stages. 

 

Estimates of funding within the NIH in 

aggregate for “arthritis research” from 2008- 

2012 have been $232M, $246M, $239M, 

$231M, and $225M 8 .Therefore, despite the 

flat NIH budget, total funding for research 

defined as “arthritis” is dropping, and the 

effect of that change on research capabilities 

is additionally magnified by inflation and 

mandated salary increases. There also 

remain substantial differences in research 

support for rheumatic diseases relative to 

other conditions. For example, in 2010 the amount of research support for RA was


 

 

development grants. The T32 success rate for renewals at NIAMS was 50% in 2010 and 36.8% in 2011 

and 67.9% versus 50% for NIAID, respectively, resulting in several major academic programs losing 

funding either transiently or permanently 11 . Finally, the NIH has also recently decreased the salary cap 

by $20,000 on support from grants, to below the current salary of many senior academic rheumatology 

MD scientists, and alternative funding sources are decreasing in level at the same time. The possible 

effect of budget reconciliation (mandated cuts to NIH, Medicare and Defense agreed upon by the US 

Congress in 2011) is unknown, but estimates that the total NIH budget will be reduced by a substantial 

percentage portend additional reductions in research support for established and new investigators, 

dramatically worsening the funding crisis. As shown in figure 1, overall funding for rheumatology 

investigators has declined significantly over the past three years. 

One example of successful innovative partnerships with the NIH is provided by the bridge funding 

mechanism for rheumatology trainees and early stage faculty members, which has been supported 

through a new Rheumatology Research Foundation program (co-funded with the Arthritis Foundation). 

Funding has been provided for 17 recipients to date. Of the 12 who have finished their year of bridge 

funding, 11 have subsequently received an NIH K Award. The Foundation invested $805,938.24, which 

resulted in over $5.8 Million in NIH support 12 . 

Total Rheumatology Research Foundation funding to ACR members for the support of research and 

research training has had a rapidly increasing positive impact on academic rheumatology 12 . Since 1985, 

the Foundation has committed over $70 million in support through 2,000+ awards and grants. In 2011, 

the Foundation disbursed funds to over 200 individuals and institutions for a total commitment of $8M. 

In 2012-2013, the Foundation is expected to fund up to $22M in rheumatology awards and grants. The 

Foundation’s Within Our Reach program (funding $30M in grants) has resulted in subsequent NIH grant 

support of at least $59M by WOR grant recipients, indicating a substantial return on investment. More 

than 75% of career development awardees have received subsequent external funding 13 . The 

reorganization of the portfolio in 2008 to focus on protected time in early career development has 

resulted in 83% retention of funded individuals in academic medicine, 77% of whom received 

additional funding, reflecting an increase in the overall academic success rate of individuals 

supported 12 . 

November 2012 18


As shown in figure 2, additional 

important research support has been 

provided by private funding agencies, 

which have contributed at least $95M 

to funding ACR members from 2006- 

2011 14 . 

There are several reports and 

ongoing efforts by other organizations 

that address the crisis in research 

funding and the decline in the relative 

impact and status of research in the US 

as compared to global competitors 15 . 

These reports focus on growing 

problems in basic, translational and 

clinical research, as well as in training 

efforts. Thus, there are many potential 

partners with which the College could 

interact when addressing these issues, potentially increasing the impact of these efforts. 

Figure 2. Private funding for rheumatology research, by % total private research 

dollars awarded to ACR/ARHP members for the period FY 2006-2011 and 

includes only agencies who responded to the request for information. 

 

 

 

 

As the amount of funding being directed to Research and Development within pharmaceutical 

companies steadily decreases, and leadership within these companies looks to academic medicine to 

replace those efforts, there are increasing opportunities for scientists within academic rheumatology 

to develop new and innovative industry partnerships. 

PhD scientists who pursue basic research are increasingly being asked by funding agencies to provide 

authentic clinical relevance to their proposed projects. 

Graduate level trainees in the United States increasingly originate from non-US countries and are often 

among the best and brightest from these countries. Policies to retain these individuals within the US 

work force, rather than to encourage their return to their home countries, are being proposed by 

several professional groups as a means to improve the quality and scientific impact of the US academic 

faculty scientific pipeline 15 . 

The “science” of rheumatic disease is rapidly expanding, leading to new research and clinical care 

opportunities in a broad array of disciplines. These areas include immunotherapeutics, autoimmunity, 

bone biology, osteoimmunology, pulmonary biology, mucosal immunology, pain medicine, 

musculoskeletal ultrasound imaging and many others. This expansion provides new opportunities for 

sub-specialization within rheumatology, a process which will also likely draw new individuals into the 

field of rheumatic disease research and clinical care. 

November 2012 19


3.1.2. Recommendations: Funding 

3.1.2.1. Develop a method and schedule to acquire and analyze in real time sufficient levels of 

serial data to provide informed recommendations regarding strategies to improve 

funding within academic rheumatology 

• Specific: This recommendation targets the information gap, especially with regard to real time data 

that can be tracked longitudinally, and allows for more meaningful analyses of the effects of future 

interventions. The goal would be to develop a method and routine schedule to acquire and analyze in 

real time sufficient levels of serial data from the NIH, other research-focused agencies and academic 

rheumatology programs to provide informed recommendations regarding strategies to improve 

funding within academic rheumatology and enhance the efficiency and impact of NIH research funding 

for academic rheumatology. This may include the addition of staff with expertise in the library 

sciences, as well as a formal liaison reporting relationship between the NIAMS Council and COR. 

 

 

 

 

Measurable: Achieving this goal will allow presentation by the COR of annual reports of research 

funding in academic rheumatology, with an analysis of changes over time. The COR will also be able to 

provide more data-driven recommendations regarding modifications of College and/or Foundation 

resources to maximize success. 

Attainable: Previously the College has intermittently performed such types of data acquisition and 

analyses, and these types of data were generated and used as the rationale to develop the 

Foundation’s Within Our Reach program. Intermittent “snapshots” have also been taken on an 

approximate five-year cycle. Acquiring data during the current Blue Ribbon Panel process from NIH and 

other funding agencies was extremely challenging, but possible 16 . However, data sets were incomplete, 

and the time and effort required to analyze it in a meaningful way was beyond the capacity of the 

available staff and volunteers. In addition, to understand changes over time, it is necessary to perform 

annual updates and analyze data in a consistent manner over time. Finally, working with individual 

academic rheumatology divisions to acquire data regarding funding and other quantitative information 

has been found in previous activities to be possible. This latter approach will likely be the primary 

method of analysis. 

Relevant: This goal is highly relevant to academic rheumatology and has been suggested in a series of 

prior reports as a means to better inform College and Foundation organizational decisions. 

Timely: The goal of acquiring and analyzing the first data set should be achievable within one year, and 

thereafter the process should be supported annually to understand changes over time. 

Brief Statement of Strategies and Tactics: To achieve this objective, a project should be submitted by the COR 

to the ACR Board, and the College and/or Foundation should commit sufficient additional personnel and 

resources to accomplish it. The GAC may also play a role in this initiative, potentially recommending that 

November 2012 20


federal funders reorganize their data in such a way that it may be used more effectively by organizations for 

strategic planning and partnership efforts. 

Resources: Achieving this outcome will likely require the addition of a dedicated staff member with an 

informatics background who will work directly with the NIH and academic rheumatology divisions to acquire 

analyze and present these data. It will likely also require additional, or refocused, time from COR and GAC 

members. 

3.1.2.2. Improve the review of rheumatic disease research within the NIH Center for Scientific 

Review (CSR) through the development of a new study section with a preponderance 

of members with expertise in rheumatic disease clinical research. 

 

 

 

 

Specific: The great decrease in targeted funding efforts by NIAMS and NIAID for rheumatic disease 

translational research through centers and specific requests for applications (RFA) that underwent 

internal grant review processes with rheumatic disease experts, and the subsequent necessity for 

rheumatology researchers to seek funding through investigator initiated grants requiring NIH Center 

for Scientific Review (CSR) review, has once again brought forward chronic problems that rheumatic 

disease investigators face within the current CSR study section structure. There are no CSR study 

sections with a preponderance of rheumatic disease research expert reviewers, especially in the area 

of clinical research. Because of this, the ACR should work to increase the quality and numbers of 

experts within the current study sections, as well as work to develop a new CSR study section with 

appropriate expertise to review rheumatic disease clinical research. The latter goal is arguably one of 

the most critical issues to maintaining the viability of academic rheumatology. Essential to the success 

of this effort will be the development of formal data concerning current relative success rates in 

clinical, translational and basic rheumatic disease research by the existing study sections that assess 

rheumatic disease research, as well as ongoing efforts to quantify these results as the anticipated 

changes in review processes occur going forward. 

Measurable: Metrics for this recommendation will include the number of rheumatologists on existing 

CSR study sections, the acquisition of necessary data to guide recommendations for change, as well as 

the development of a primary study section for rheumatic disease clinical research. 

Attainable: The rheumatology community has a cadre of experts who are well suited to provide 

comprehensive review for rheumatic disease grants. The rheumatology research community will need 

to be fully engaged and encouraged to participate in this process in order for this initiative to be 

successful. 

Relevant: The goal is relevant because it is focused on the maintaining the health of academic 

rheumatology research, which also allows other key educational and clinical care missions to be 

pursued. 

November 2012 21


 

Timely: Having routine access to high quality scientific review of rheumatic disease research is 

necessary to achieve all of the other academic rheumatology research goals. 

Brief Statement of Strategies and Tactics: The COR and ACR leadership, along with the GAC and external 

partners, should utilize all necessary resources to achieve the goals outlined in this recommendation. 

Resources: This recommendation will require additional direct support from ACR leadership as well as relevant 

committee members and staff. 

3.1.2.3. Establish additional formal and informal interactions with a targeted group of 

professional and lay research-intensive organizations to identify common policy and 

funding goals that can be pursued in a collaborative manner. 

 

 

 

 

 

Specific: This recommendation targets the ability of the College to increase its impact in high priority 

policy areas by working with other research minded organizations (for example, American Association 

of Immunologists (AAI), Federation of Clinical Immunology Societies (FOCIS), Alliance for Lupus 

Research (ALR), Lupus Research Institute (LRI), Scleroderma Foundation), who share specific goals with 

us. In addition, these discussions could lead to research funding partnerships that may benefit 

academic rheumatologists. 

Measurable: Organization by the Foundation in collaboration with COR of a series of summit meetings 

of research-minded organizations to identify common goals, and then follow through of the 

recommendations from these meetings. 

Attainable: There are historical and highly successful examples within the College of similar “summit” 

meetings with groups who share similar goals. 

Relevant: This goal is focused on enhancing the impact of the College and Foundation on policies and 

processes that are keys to its success. In addition, there are many ACR goals that are shared with other 

organizations. Finally, such interactions can potentially lead to programs with direct financial benefit. 

Timely: The process is timely because there are many ongoing efforts to address the current funding 

crisis and other aspects of research funding and leadership. An initial pilot “summit meeting” could be 

organized by the Foundation and held within the first year, and a brief report generated. The process 

could then be expanded to re-occur formally on a specific schedule (e.g., annually) and informally as 

needs arise. 

Brief Statement of Strategies and Tactics: Establishing the summit meetings and other types of interactions 

with collaborating organizations, along with providing an agenda for discussion and innovation, will position 

the ACR as a leader of research minded organizations that pursue common or related goals relevant to 

rheumatology research. 

November 2012 22


Resources: Achieving this outcome will require additional, or refocused, volunteer time from COR members 

who will have specific “deliverables” in this area, additional commitment by ACR leadership to interact with 

leaders of these organizations, and the addition of a dedicated staff member who will work directly with the 

other organizations to set up calls, meetings and other interactions, as well as follow up on action items and 

projects resulting from these meetings. 

3.1.2.4. Increase formal intra-organization interactions with the Government Affairs 

Committee and RheumPAC to assure that there are timely and focused researchrelated 

legislative recommendations pursued by the ACR. 

 

 

 

 

 

Specific: This recommendation targets the need to increase the impact of the ACR on policies directed 

towards enhancing academic rheumatology, by utilizing all of the available ACR resources, especially 

those that have been recently developed and/or expanded. 

Measurable: The GAC has been increasingly successful in its metrics of achieving legislative goals, and 

additional goals relevant to academic rheumatology would be assessed in a similar manner. 

Attainable: Leadership within the GAC is open to expanding its “portfolio” to include additional areas 

that impact academic rheumatology. Funding issues are but one of the many policy goals that could be 

pursued. 

Relevant: This process is meant to assure that all relevant resources of the ACR are utilized to achieve 

the goals of the organization with regard to academic rheumatology. 

Timely: With the ongoing intersection of the research funding crisis and health care reform, along with 

an uncertain outcome of each, there are many opportunities to influence decisions now that will have 

longstanding benefits. 

Brief Statement of Strategies and Tactics: The COR should develop, along with the GAC, a broad-based 

legislative agenda that could be pursued together. Additional cross-appointments within GAC and COR of 

individuals who are representative members should be pursued in order to formalize the interactions over 

time. 

Resources: Achieving this outcome will require additional, or refocused, volunteer time from COR and GAC 

members, and dedicated interactions between GAC and COR staff members who will work directly. 

November 2012 23


3.1.2.5. Continue very successful efforts by the Foundation to expand funding that supports 

the academic rheumatology research enterprise and the research training pipeline. 

Strong consideration should be given to expanding bridge funding to additional 

transition points within academic research careers. 

 

 

 

 

 

Specific: The Foundation has been spectacularly successful in its recent efforts in this area. In addition 

to direct impact on academic rheumatology, the continued success and expansion of funding provides 

substantial leverage for the College in its interactions with governmental and lay organizations. 

Measurable: Metrics for this recommendation will include the number of individuals who transition to 

a position that is within or highly supportive of academic rheumatology, in addition to the amount of 

additional funding and research that is “leveraged.” It is important to demonstrate successful 

competition for R0I and other NIH awards as metrics to provide positive feedback to philanthropists 

and industry, in order to encourage more support. 

Attainable: The Foundation has demonstrated repeated success with this process, in addition to the 

ability to raise an increasing amount of financial support from external sources. 

Relevant: The goal is relevant because it is focused on the financial health of academic rheumatology 

and to the pursuit of its research and educational/training missions. 

Timely: The Foundation is well positioned to address, at the current time and into the future, the 

ongoing crisis in funding and to leverage its support into additional funding from the NIH and other 

research-minded organizations. 

Brief Statement of Strategies and Tactics: The Foundation will continue to seek external financial support and 

partnerships to pursue a targeted research agenda that, in addition to scientific advancement and training 

support, has as one of its primary goals the support of academic rheumatology. 

Resources: This recommendation will not require additional direct support from volunteers and staff beyond 

that already committed. 

3.1.2.6. Aggressively advance the rheumatology research agenda with a focus on utilizing this 

document to increase awareness and funding for the major rheumatic diseases. 

 

Specific: There is a relative lack of funding for rheumatic diseases as compared to the impact of the 

diseases on the population. The research agenda is a carefully crafted document that describes the 

research opportunities within the field. Other ACR entities, for example the GAC, currently supports a 

broad increase in research funding but do not focus on the specific areas of emphasis put forward 

within the research agenda. A closer relationship between the COR and other College entities, such as 

the GAC, with a goal of increasing the impact of the document, would bring additional considerable 

November 2012 24


 

 

 

 

organizational strengths more in line with specific goals in the area of academic rheumatology research 

funding. 

Measurable: The primary goal of increasing funding in alignment with the research agenda will be 

addressed by the development of a plan by the COR and GAC, in close collaboration with the SAC and 

others, to engage congress and other stakeholders in this area. Developing partnerships with researchfocused 

groups identified through efforts in recommendation r3.1.2.3 will help to advance the primary 

goals. 

Attainable: The goal is believed to be both attainable and measurable through mechanisms developed 

in Recommendation 3.1.2.1. As one example of potential partnerships with high impact, the GAC is 

achieving measurable success in its legislative goals around access to care, payer reform, and other 

issues; therefore, joining forces between the COR and GAC is very likely to succeed. 

Relevant: Achieving this goal should increase the overall level of research support for academic 

rheumatology. 

Timely: Increased funding of rheumatic disease research is a primary goal of the Blue Ribbon Panel 

efforts. These efforts can be enhanced by novel partnerships envisioned in other recommendations 

within this and other issues. 

Brief Statement of Strategies and Tactics: The COR would pursue discussions with the SAC and GAC and other 

organizational entities to pursue these funding goals. Discussions with lay organization and industry partners 

would also be used to promote this goal. 

Resources: Achieving this outcome will require additional, or refocused, volunteer time from COR, GAC and 

likely SAC members and the assignment of a dedicated staff member who will work directly with the other 

potential partners to set up calls, meetings and other interactions, as well as provide follow up and 

management of outcomes of these interactions. 

3.1.2.7. Develop strategic funding approaches to the multitude of low prevalence rheumatic 

diseases, found especially in children. 

 

 

Specific: Research in rheumatology is broad and dispersed among a wide variety of diseases with 

relatively low prevalence, falling under orphan or ultra-orphan designations. Many of these diseases 

are found in children. Although it is challenging to obtain basic and translational research support for 

these diseases using traditional mechanisms, there is an increasing interest in the NIH, and especially 

the biotechnology and pharmaceutical industries, to identify these populations for development of 

novel therapeutic compounds. 

Measurable: The goal of enhancing funding in orphan indications would be met by establishing a series 

of meetings of NIH, industry and academic leaders who would work to develop partnerships in these 

November 2012 25


 

 

 

areas. Mechanisms for measuring disease-specific funding for rare rheumatic diseases would need to 

be employed. 

Attainable: Expanding funding in orphan indications is considered a “stretch goal”, as there has not 

previously been a similar effort within the College. However, the NIH and FDA have previously worked 

with members of the College to establish lupus therapeutic guidelines and outcome measures, so there 

is a history in the field of successfully pursuing trans-organizational goals. In addition, many of the 

orphan diseases are found within pediatric rheumatology, and this community has had some 

remarkable successes in collaborative efforts such as CARRA. 

Relevant: Achieving the goal of increased support for orphan indications should increase the overall 

level of research support for academic rheumatology. This focused approach would also serve to 

distinguish the College and academic rheumatologists as professional entities interested in utilizing 

novel methods to support the diagnosis and care of patients with unusual conditions. 

Timely: Increased funding of rheumatic disease research is a primary goal of the Blue Ribbon Panel 

efforts. These efforts can be enhanced by novel partnerships envisioned in other recommendations 

within this and other issues. 

Brief Statement of Strategies and Tactics: Discussions with lay organizations and industry partners would also 

be used to promote this goal. 

Resources: Achieving this outcome will require additional, or refocused, volunteer time from COR and likely 

the SAC, along with volunteers from pediatric rheumatology, and additional dedicated staff time to work 

directly with the other potential partners and set up calls, meetings and other interactions. It will be important 

to engage members of the Foundation’s corporate roundtable in these discussions. 

November 2012 26


3.2. Redefining the scope and heterogeneity of rheumatology, with broader reach throughout clinical 

immunology and musculoskeletal medicine: promoting expansion by sub-specializing within areas of 

rheumatology and incorporation of new clinical, research and training dimensions 


Rheumatology is a broad field that encompasses musculoskeletal medicine and a spectrum of systemic 

autoimmune diseases, some of which are associated with inflammatory arthritis. Important advances in 

understanding and treating rheumatic diseases have occurred in the 14 years since the last report on 

academic rheumatology, including the following developments: 

 

 

 

 

 

 

 

Biologic therapeutics have dramatically changed the management of inflammatory arthritides and, more 

recently, some forms of systemic vasculitis, and rheumatologists have become the premier clinical experts 

in the use of biologics that affect immune and inflammatory responses. 

The College has established clear guidelines for the safe use and monitoring of conventional and biologic 

therapeutics in RA 17 , that are used in patient management by rheumatologists, rheumatology nurse 

practitioners and physician assistants, and their clinical practice extenders, not only in the treatment of RA 

but also for a wide variety of diseases. 

A growing number of diseases managed by specialists in other clinical disciplines (dermatology, 

ophthalmology, otorhinolaryngology, neurology, etc.) have been found to be immune-mediated, and many 

of these diseases are increasingly treated using immune suppressive and biologic drugs identical to those 

familiar to rheumatologists 18-21 . 

Such patients are increasingly referred to rheumatologists for disease management by other subspecialists 

who are unprepared to consider or use immunosuppressive and biologic drugs safely and effectively, 

beyond assessment of the clinical activity of the disease that is under treatment. 

At the same time, rheumatologists may be unfamiliar with these “non-rheumatic” diseases and lack the 

instrumentation and/or necessary training and skills to assess their level of activity on physical 

examination. As one ACR member wrote in comments addressed to this panel: “Some of the diseases I 

now see and treat I could not even pronounce 10 years ago.” 

Advances in basic and translational science, spearheaded by rheumatology researchers, have led to the 

definition of an expanding spectrum of genetic 22 and acquired autoinflammatory diseases 23 that are 

mediated by innate immune mechanisms, many of which respond optimally to blockade of pathogenic 

cytokines. 

Increases in our knowledge of the natural history of autoimmune diseases across the broad spectrum of 

target organs has led to the understanding that there almost universally is a long period of serologically 

detectable autoantibodies and other biomarkers with potentially a sufficiently high enough predictive 

value to allow prevention strategies to be employed that are similar in concept to those typically used in 

November 2012 27


 

cardiovascular disease. This emerging situation opens up broad scientific and clinical opportunities. 

However, how to translate these findings into clinical medicine, and which physicians would be the 

“content experts” for screening and prevention approaches across the broader field of autoimmunity, 

remains undefined and is thus a potential opportunity for rheumatology expansion. 

Meanwhile, the mechanisms and management of chronic pain disorders, such as fibromyalgia, have been 

redefined, and the first FDA-approved therapeutics for fibromyalgia have been approved 24 . The 

importance of pain as a central theme in rheumatology clinical practice was emphasized in a recent ACR 

 

report produced by a task force led by Dr. David Borenstein 25 . 

Many rheumatologists have adopted advanced in-office imaging of musculoskeletal structures as a 

diagnostic tool, a method of monitoring effectiveness of treatment of arthritis, and an aid to aspiration 

and injection of joints and periarticular structures. The interest of the College in this topic is reflected in a 

recent white paper 26 , an upcoming paper in A&R (November 2012), and by educational offerings in 

musculoskeletal ultrasound. 

3.2.2. Recommendations: Redefining Scope 

3.2.2.1. Develop a program and schedule for defining and tracking the scope of the specialty of 

rheumatology, to stay ahead of the curve with respect to the ever-changing landscape 

of the practice of medicine in the US. 

The expanding scope of rheumatology needs to be defined and tracked at frequent intervals by the ACR, 

through the CORC, COR and COTW. ACR and ARHP educational programs (including invited reviews in ACR 

journals) should reflect this scope, with special attention to newer developments and diseases newly added to 

the range of our expertise. 

In addition, the rheumatology fellowship curriculum will need to keep pace with the more rapid changes in the 

clinical scope of rheumatology. 

 

 

Specific: Assigns specific tasks to four committees for analysis and implementation. 

Measurable: Metrics for this goal include 1) monitoring the topics of articles published in the major 

rheumatology journals and monitoring growth in specific areas (e.g., systems or diseases ‘new’ to 

rheumatology); 2) Monitoring the use of codes across rheumatology practices and tracking changes 

over time; 3) scheduling routine updates to the curriculum and tracking frequency of changes over 

a specific time period; 4) obtaining input from members of CORC, CJP, COR and COTW; 5) 

submission of a report annually to the Board of Directors that updates the scope of rheumatology. 

November 2012 28


 

 

 

Attainable: With the current resources available (including the journals, registry, CORC, COTW and 

COR groups), it is reasonable to expect that the College could develop a dashboard or method to 

measure the scope of the specialty over the next 18-24 months. 

Relevant: This goal is relevant to all aspects of the specialty as it will affect academics and practice, 

drive changes in training curricula and broaden the research arena to new systems and diseases. 

Timely: This scope of the specialty has grown tremendously over the past decade. In addition, this 

goal is particularly timely as the College will launch its musculoskeletal ultrasound certification 

program in the coming year, and a new strategic planning cycle will be initiated soon. 

Strategies and Tactics: Charge the CORC, CJP, COE, COR and COTW to develop a dashboard to track trends and 

changes in the scope of the specialty. Attendance at professional meetings should be tracked over time to 

determine the level of interest in specific topics outside the typical ‘scope’ of rheumatology. In addition, CORC 

should track the use of codes over time to determine emerging areas. CJP could conduct a thorough analysis 

of its article topics over time to determine burgeoning areas of research. COR could track rheumatology 

research funding to determine new disease areas added to the portfolio over time. The COTW would then 

need to frequently update the rheumatology fellowship curriculum and the in-training exam to keep up with 

the more rapid changes in the clinical scope of rheumatology, and provide effective liaison to the ABIM in this 

area. 

Resources: Completion of this objective would require significant time investment on the part of staff and 

volunteer time in clinical practice , research and training, and education areas to a) build the dashboard and 

populate with baseline data; b) develop methodology, processes, and a routine schedule to track specific data 

points over time; c) collect data and input from key constituents; d) prepare regular reports to key 

stakeholders and e) liaise with ACGME and ABIM, NBME to implement changes to the curriculum and exams 

as needed. 

3.2.2.2. Develop advanced fellowship training or ‘sub-specialization’ programs. 

The two year rheumatology fellowship (three years for pediatric rheumatology) should continue to provide 

comprehensive training in both aspects of rheumatology, loosely termed here as “musculoskeletal medicine” 

and “clinical immunology.” New models in which a third year of fellowship is devoted to advanced training in 

one of the two subfields should be considered. This initiative will require careful planning under the 

supervision of the Committee on Training and Workforce with input from the Rheumatology Program 

Directors. Models for financing this third year may be available from the few programs that already offer it, 

and from initiatives such as an inter-institutional vasculitis fellowship that currently exist. 

November 2012 29


 

 

 

 

 

Specific: This recommendation is specific to ACGME adult and pediatric rheumatology programs in the 

US (N= 108 adult, 30 peds). 

Measurable: The metrics for this program would be easily obtained via survey to program directors and 

fellows participating in this program. Subsequent downstream parameters that would measure the 

efficacy of additional training might be based on domains such as revenue, patient populations, codes 

and treatments. 

Attainable: With the current resources available to track the needs and trends within the specialty, it is 

reasonable to expect that the College could partner with academic divisions of rheumatology to 

execute pilot programs in a small number of test sites within 3 years, with a test period of at least 5 

years to determine the impact of the programs. In the interim, specialists in specific areas may 

designate their area of expertise or ‘specialty’ with respect to treatment, research, or both in the 

expanded member profile through the website. This would be an easy way to use an existing resource 

to identify who the experts are in different areas. 

Relevant: This is especially relevant as the scope of the specialty continues to change and grow, and as 

rheumatology continues to treat a highly diverse spectrum of the most complex cases. 

Timely: The College has already shown a commitment to equipping its members with the tools needed 

to practice in the ever-changing clinical landscape by taking steps to develop a musculoskeletal 

ultrasound certification program. A specialized year would add to this toolbox. 

Strategies and Tactics: The COTW should be charged with the development of a framework for such training 

models and for evaluation of their success. However, consideration of formal sub-specialized certification 

within rheumatology should be postponed for about 5 years, until the assessment of these initial experiments 

is available. 

Resources: Completion of this objective would require significant time investment on the part of staff, and 

volunteer time in the training area. 

3.2.2.3. Develop collaborative interdisciplinary clinical care models. 

As the experts in caring for patients with complex diseases and complex treatment plans, our specialty should 

take a leadership role in the development of innovative and collaborative clinical care models for screening, 

evaluation and management of patients whose diseases engage the expertise of both rheumatologists and 

other subspecialists who are the traditional experts in those diseases. This goal is not aimed at primary care 

physicians, but rather other specialists involved in the care of patients with rheumatic diseases (e.g., 

orthopedists, ophthalmologists, etc.). Examples of such clinical care models already exist and are potentially 

useful prototypes for other rheumatology units. The ACR can facilitate transmission and sharing of successful 

November 2012 30


clinical initiatives that may be widely applicable. 

 

 

 

 

 

Specific: Addition of a new and highly publicized session at the Annual Meeting and/or State of the Art; 

addition of this topic to the CORC agenda at least once each year. 

Measurable: Participation in meeting sessions on this topic, number of articles in A&R, AC&R and TR. 

Attainable: With the appropriate support and resources, this is attainable within the existing 

organizational structure of the College. 

Relevant: This recommendation would help to disseminate innovative clinical models throughout the 

country. 

Timely: Members need more information about possible directions for clinical innovation. 

Strategies and Tactics: Through the COTW and CORC, academic units should be encouraged to develop 

innovative and collaborative clinical care models for screening, evaluation and management of patients whose 

diseases engage the expertise of both rheumatologists and other subspecialists who are the traditional 

experts in those diseases. A session focused on innovative models of clinical care should be organized 

periodically at the annual meeting or other professional meetings. College publications, such as Arthritis Care 

and Research and The Rheumatologist can serve useful roles in educating rheumatologists on this subject. 

Resources: Volunteer and staff time in the clinical, education and training areas to develop best practices 

documents and communications for distribution to academic centers with adult and/or pediatric 

rheumatology programs. 

3.2.2.4. Develop meaningful partnerships to create disease management guidelines for 

conditions whose care requires coordinated efforts between rheumatologists and 

other specialties. 

 

 

 

 

 

Specific: New joint efforts with other US-based professional specialty societies in disciplines that 

collaborate with rheumatologists in clinical practice. 

Measurable: Number of products (guidelines, criteria, etc.) produced as a result of such 

collaborations. 

Attainable: This will require a ramp-up period to select topics of interest, cultivate new 

collaborations with other societies, harmonize procedures for each project, and complete the 

project. The ACR can aim for one product by mid-2015. 

Relevant: This work will establish the role and influence of rheumatology in disease areas 

previously at the margin of our discipline. 

Timely: This activity will help the ACR keep up with the rapidly changing landscape in rheumatology 

clinical practice. 

November 2012 31


Strategies and Tactics: The ACR Quality of Care Committee should partner with other professional 

organizations to develop criteria, disease measurement tools and management guidelines for diseases treated 

by rheumatologists that are outside the traditional boundaries of the field of rheumatology. These efforts will 

firmly establish new areas of disease as within the spectrum of rheumatology clinical practice, research and 

training. 

Resources: This will require a dedicated budget, as well as volunteer and staff time in the quality and practice 

areas. 

November 2012 32


3.3. Developing research consortia and infrastructure 


 

 

 

Databases, biorepositories, registries and research consortia enable clinical and translational research 

projects investigating rheumatic diseases, and are central and critical resources to academic 

investigators in our field. Such resources provide the basis for innovative and transformational 

research in rheumatic disease, and without access to these, it is difficult to directly characterize the 

role of pathways and molecules in rheumatic diseases, and to test new therapies in clinical trials. Thus, 

providing rheumatic disease investigators access to these resources will further promote the objectives 

of the College to advance our understanding of disease pathogenesis, and improve our ability to 

diagnose and treat rheumatic diseases. Different approaches may be needed for different diseases, for 

databases vs. biorepositories vs. registries, and for samples from clinical trials vs. cohort studies. How 

can the College better support investigators in the use of these resources? 

Many successful research registries and consortia that have been established in Europe are 

longstanding and are quite successful. Examples include the British Society for Rheumatology Biologics 

Registry, which collects data that can be accessed for research projects, helps members to design 

studies, and supports the coding and reporting of adverse events 27 ; and the international Vasculitis 

Consortium that conducts collaborative trials in the treatment of uncommon vasculitic diseases. These 

resources have facilitated collaborative research projects that could not have otherwise been 

accomplished. Given the current direction of research, with emphasis on large, highly collaborative 

projects, as well as the “Roadmap” initiative at the NIH, it will be important for the College to position 

itself and its members to take advantage of this trend. 

During the past decade, several successful research consortia have been developed in the United 

States, with the stated goals of either developing research resources for the scientific community or of 

working together to conduct research that can best be performed as part of a consortium. Typically, 

research consortia have a specific focus both in terms of disease and the types of studies to be 

supported, such as genetic studies, and the projects supported have large sample size requirements or 

require exceptionally large and/or diverse resources. Examples include: 

o North American RA Consortium (NARAC), funded by NIAMS with a small contribution at the 

outset from the AF, with a stated goal of developing a resource to support genetics studies 

of RA; 

o The newly established Lupus Nephritis Trials Network, which was supported in part by the 

College, was recently formed under the leadership of Drs. David Wofsy, Betty Diamond, 

Frédéric Houssiau and Brad Rovin. This network is intended to bring together investigators 

under a common set of policies and procedures for the conduct of research in the area of 

lupus nephritis, including review of methodology and study design, publication policies; 

November 2012 33


 

 

 

o Lupus Multiplex Registry and Repository (LMRR), also funded by NIAMS to support 

development of a resource for genetics studies of lupus; 

o Multiple autoimmune disease genetics consortium (MADGC), supported by NIAID to 

develop a resource for genetics studies of autoimmune diseases; 

o SLE international genetics consortium (SLEGEN), initially funded with support of the 

Alliance for Lupus Research and now largely supported by a P01 grant from NIAID; 

o International Sjögren’s syndrome registry (SICCA), which has been funded largely by the 

NIDCR; 

o The Arthritis Internet Registry (AIR), funded by the Arthritis Foundation, allows for online 

patient reporting with local collection of blood and serum; 

o NIH- NIDDK Inflammatory Bowel Disease Genetics Consortium (IBDGC) Ancillary Study 

Program administered through Yale University; and 

o CarraNET has received NIH funding for clinical research in pediatric rheumatology and has 

59 sites participating. 

This list is not exhaustive, and several other successful registries, networks and consortia have 

been developed, including the TETRAD database, the SPARTAN network, and the NIH-funded 

Immune Tolerance Network. Overall, these efforts have succeeded in terms of their initial goals, 

which are to develop resources in areas that require large investments. The initial investments had 

a high rate of return, to the extent that these resources for research have been shared by multiple 

investigative groups. Further, such research resources are ideal for use in K award projects and 

other projects to be undertaken by junior investigators, as these awards typically provide salary 

support, but limited funding for the projects themselves. Since the requisite data and 

biospecimens already exist, the cost associated with research that utilizes these resources is 

dramatically reduced. 

However, these existing resources have not been maintained and utilized to their maximum 

potential. Reasons include: 1) lack of funding for ongoing maintenance of the research resources; 

2) limited efforts to “advertise” and ensure wide access to the data, and 3) the very limited 

funding opportunities available for effective utilization of these research resources. Thus, large 

investments have been made to develop these valuable research resources, but maintenance is 

costly and has not been uniformly supported, and investigators have been limited in their ability to 

fully utilize these valuable resources by funding constraints. 

To date, the College has played a limited role in the development, maintenance and utilization of 

such research resources. Given the reduction in NIH dollars available for these and other research 

efforts, the College has an opportunity to support research utilizing such existing resources, and 

also to consider the development of other research resources for which a need exists (for 

example, rare rheumatic diseases). 

November 2012 34


 

 

Possible research tools that the College could develop to encourage/aid in research efforts for 

members include biorepositories, databases and tissue banks. However, similar resources have already 

been developed in many areas that are not being used to their best advantage, such as the repository 

of samples from the NIH OA Initiative. It is unclear whether this is because these sample repositories 

are not well publicized, are too difficult to access, or whether samples are simply not collected in a 

manner useful to most investigators in the field. 

Biorepositories, databases and tissue banks face multiple challenges in this era of cost-constraints and 

reduced funding rates. These include: 

o Expensive to collect and store biological samples 

o Expensive to collect and store robust clinical data 

o Long-term commitments to build and maintain such resources are essential and are often 

lacking 

o Support from the NIH to maintain these is lacking 

o Frequently individual-investigator driven and too dependent for maintenance on the 

continuous efforts of one investigator 

o Barriers to access for junior investigators, investigators outside of the “inner group” 

o Limited supplies of biological specimens 

3.3.2. Recommendations: Research Consortia 

3.3.2.1. Address potential underutilization of existing registries and biorepositories 

The College has invested heavily in the Rheumatology Clinical Registry, and is currently expanding these 

efforts through Rheumatology Information Systems for Effectiveness (RISE) to create a federated system of 

clinical data abstracted from local EHRs. The panel recommends that these efforts include a focus on potential 

research applications, which may change the way in which data is collected, stored, and queried. In addition, 

the panel recommends that the College support and invest in the integration of existing registries into a 

centralized registry through the RHIT Committee. Opportunities to expand and improve the capabilities of this 

type of database should be investigated further by the RHIT. 

• Specific: This recommendation targets the underutilization of existing databases and 

biorepositories and utilizes existing ACR resources with the recommendation to build capacity 

in this specific area in the future. 

• Measurable: Increased use of the centralized registry can be tracked by requiring investigators 

to cite the ACR database in publications resulting from their work using the data. 

• Attainable: The College has taken important steps to build up their registry area over the past 

few years, and laid the groundwork for this goal. 

• Relevant: As research in rheumatic diseases moves more and more toward large collaborative 

initiatives, and the use of biomarkers, serum and tissues from rheumatic diseases becomes 

November 2012 35


more critical for translational research efforts, the use of existing databases, biorepositories 

and tissue banks, as well as registries for clinical trials becomes increasingly important. The ACR 

should take the lead in compiling these resources and making them available in a central 

location (via the ACR registry portfolio) to the ACR research community. 

• Timely: RHIT could explore expansion and improvement of the existing ACR registry portfolio 

over the next 2-3 years. 

Brief Statement of Strategies and Tactics: RHIT (with assistance and input from COR and the Foundation) 

should collaboratively explore and formally consider this recommendation and its implementation over the 

next 2- 3 years. The RHIT committee should also include establishing a formal liaison relationship with the 

COR. 

Resources: Cost to the ACR will be substantial, and would be determined by the RHIT in subsequent requests 

to the ACR Board. 

3.3.2.2. Maintain valuable collections and sources of patient data and biological samples. 

• Specific: This recommendation targets the need to maintain valuable resources and to support 

investigators performing clinical and translational research that utilizes these existing 

resources. In addition to including integration of existing registries into the ACR’s registry 

portfolio; this may also include the development of new Rheumatology Research Foundation 

awards to support the utilization of existing registries, as well as advocacy efforts to encourage 

NIH and PCORI provide funds to develop and maintain databases and biorepositories 

• Measurable: Quantitate the resources “saved” by this mechanism and the number of articles 

published/grants obtained by investigators using the resource. 

• Attainable: Given the ACR’s investment in the registry portfolio, it is reasonable to expect this 

could be achieved once a budget is established. There may also be an opportunity to enter into 

strategic partnerships with groups who have established biorepositories. Foundation funding 

for these efforts should also be considered. The Foundation’s resource sharing policy for 

funded studies should also be carefully considered. 

• Relevant: As research in rheumatic diseases moves more and more toward large collaborative 

initiatives, and the use of biomarkers, serum and tissues from rheumatic diseases becomes 

more critical for translational research efforts, the use of existing data bases, biorepositories 

and tissue banks, as well as registries for clinical trials becomes increasingly important. 

• Timely: Currently several important databases cannot be further supported, and the NIH has 

limited funds for maintenance. There is a risk of losing resources that were costly and time 

consuming to organize. 

November 2012 36


Brief Statement of Strategies and Tactics: This recommendation would require a significant input of resources 

by the College and Foundation, and may require new fundraising initiatives. Before any new grant initiatives 

are undertaken, it is recommended that the COR and RHIT work together to discuss prioritization of the 

possibilities outlined above, and develop a proposal for consideration by the Foundation for new initiatives in 

the area of biorepositories. Finally, RHIT, COR and GAC should consider increasing our lobbying efforts for 

additional NIH support in the areas discussed above. 

Resources: This recommendation will require resources and time from staff and volunteers in the areas of 

RHIT, COR, GAC and the Foundation. There are significant budgetary implications if the College chooses to 

develop its own centralized biorepository. Should the Foundation choose to go forward with new grant 

initiatives in this area, it would require re-allocation of existing funds, or new fundraising efforts. If new 

fundraising is required, this is an additional burden for staff and volunteers. 

3.3.2.3. Leverage existing funding sources by partnering with the CTSAs and with Industry. 

This recommendation has three specific aims: 

A. To convene a summit meeting of CTSA leaders to discuss ways to maximize funding and leverage 

existing programs to encourage cross-collaboration; 

B. To consider new funding opportunities through the Foundation to leverage programs within existing 

CTSAs, including providing matching funds for pilot grant programs 

C. To consider a new Rheumatology Research Foundation grant mechanism similar to the STTR grants at 

the NIH that leverage collaborations with Industry 

 

 

 

 

 

Specific: This recommendation targets the limited availability of funds for academic researchers 

engaged in translational research efforts, many of which utilize consortia, databases and 

repositories. 

Measurable: Quantitate publications and research grants obtained as a result of this 

mechanism. 

Attainable: Could require specific fundraising, or could be accomplished by re-allocation of 

existing funds. 

Relevant: CTSAs support translational research and are looking to fund pilot projects. The NIH is 

exploring the potential for collaborations with industry by supporting academic investigators 

with good ideas who partner with industry. The Foundation could explore this. 

Timely: In this age of limited funding opportunities for translational research, this 

recommendation serves to leverage existing funding mechanisms. 

November 2012 37


Brief Statement of Strategies and Tactics: Members of COR could partner with CTSA leadership at key 

institutions at which matching fund programs exist to develop a proposal for consideration by the Foundation 

for a new funding mechanism to provide matching funds. COR and the Committee on Corporate Relations 

could explore the possibility of similar partnerships with industry. 

Resources: This recommendation will require resources, and time from staff and volunteers at the College 

(COR) and the Foundation. There are budget implications if the Foundation chooses to go forward with new 

grant initiatives in this area. These would include either allocation of existing funds, or new fundraising efforts. 

If new fundraising is required, this is an additional burden for staff, volunteers and fundraisers. 

3.3.2.4. Organize a working group of the COR to discuss potential new research resources that 

would have high value for the rheumatology scientific community. 

• Specific: This recommendation targets the limited availability of funds for research resources 

(databases, biorepositories) in less common rheumatic diseases. 

• Measurable: Working group would be charged to quantitatively assess need and potential 

return 

• Attainable: Given the volunteer resources available through COR, this is an attainable goal. 

• Relevant: Biorepositories, databases and similar resources are difficult to develop in less 

common rheumatic diseases. This is one area where the ACR may want to consider assisting 

investigators studying these diseases. 

• Timely: In this age of limited funding opportunities for translational research, resources are 

particularly difficult to develop in less common rheumatic diseases. 

Brief Statement of Strategies and Tactics: The Committee on Research would establish a working group to 

discuss these issues and ideas, and might consider facilitating the development of selected new resources in 

underserved areas – for example SSc. 

Resources: Resources would involve additional staff and volunteer time (COR) in order to collect data on need 

and potential return. 

November 2012 38


3.4. Value-driven cost effective approaches to patient care, including development and adoption of new 

technologies, diagnostics and therapeutics. 


 

 

The impact of technology across all facets of healthcare, not to mention our society, has been 

monumental. The immediate access to virtually all published medical knowledge has sped discoveries 

in biomedical research that have led to new therapeutic candidates, and the tools that facilitate global 

communication and complex data analysis have supported the clinical testing that have brought highly 

effective drugs to patients with rheumatic diseases and substantially improved outcomes of those lifelimiting 

diseases. At the same time, the United States is challenged by our aging population and its 

burden of chronic diseases, some of which have not sufficiently benefitted from disease-altering 

medical advances, as well as the economic burdens of a growing and unwieldy healthcare system that 

will be inadequate to meet the healthcare needs of the population. The physician workforce, including 

rheumatologists, is already stressed because of insufficient numbers of skilled specialists to provide 

sophisticated management of patients receiving the life-changing biologic therapies as well as 

coordination of care for resource-intensive chronic musculoskeletal disorders. The academic 

rheumatology centers are in a position to have a major positive impact on these challenges as testing 

grounds for improved efficiencies through incorporation of the latest technologies into their clinical 

care, research and education programs. Moreover, the academic rheumatology centers can 

demonstrate their high value, not only at the institutional level, but to the healthcare system in 

general, through development of innovations in technology. As academic rheumatology centers made 

a major contribution to medicine through their significant role in development of biologic immunebased 

therapies, so can those centers have significant impact on improving patient outcomes, 

improving the professional lives of rheumatologists, enriching the education of future rheumatologists 

and demonstrating the value of the academic centers by implementing available technologies and 

creating new technologies. 

Integration of EMR systems into academic rheumatology practices will not only provide a transferable 

system for documentation of patient management, but should provide mechanisms to facilitate 

reporting of quality measures and export of data to registries useful for clinical research and 

demonstration of patient outcomes. Many currently incompatible EMR systems are in use around the 

country, the start-up process is painful, and the systems for data transfer to registries and CMS 

reporting are not yet fully implemented. The practice management components of EMRs are not 

necessarily consistent with the particular practice models of the academic rheumatology practices, and 

the EMR patient encounter templates are not necessarily designed with the complex rheumatic 

disease patient in mind. As the requirement for use of EMRs becomes universal, ACR can play an 

essential role in learning of best practices from those academic centers that are most advanced in 

November 2012 39


applying EMR systems to the needs of rheumatology practices, as well as those that have incorporated 

systems for data exchange with research registries. The ACR can aggregate and disseminate that 

knowledge, and perhaps the actual EMR tools, to all centers and non-academic rheumatology clinical 

practices. The requirement of ACGME to include training of fellows in use of EMRs in rheumatology 

training program presents both an imperative as well as a challenge for academic rheumatology 

programs. The COTW, along with RHIT, can provide guidance to its training programs through 

curriculum development. Technologies that facilitate reporting of patient-derived data will be 

increasingly important in order to complement the medical information recorded by the healthcare 

provider, to generate a visual demonstration of disease activity or therapeutic response to patients, to 

provide essential data for registries used for research studies, and to meet the growing focus on 

 

defining and documenting the outcomes that are most important to the patient 28 . Some members 

have developed such tools for patient data entry, with access to data collection programs available at 

home or at the time of the patient encounter, using hand-held devices or similar tools. The availability 

of REDCap open source electronic data capture systems will provide additional resources to these 

efforts. 

The growing recognition of the significance of the patient’s responsibility and involvement in his/her 

healthcare, along with the burdens and limitations of the physician workforce and the economic 

challenges of providing optimal healthcare to an aging population, provide strong rationale for 

development of creative clinical management tools and systems. Academic rheumatology programs 

can play a primary role in development and testing of such tools and systems that will improve 

efficiency of academic rheumatology clinical practices, provide tools for those outside the academic 

system, and provide strong demonstration of the essential contribution of academic rheumatology 

programs to their institutions and the academic and healthcare systems. The importance of 

incorporating physician extenders into patient care is acknowledged, but the details of collaborative 

care that provide the greatest value to patients and the system are not agreed upon. Systems analysis 

and the technical tools that enable telemedicine can be incorporated into academic rheumatology 

practices for care of patients with diseases that are best managed in a multidisciplinary manner 29 (e.g. 

osteoarthritis, involving contributions from rheumatologists, primary care physicians, orthopedic 

surgeons, nutritionists, physical therapists and others). Telemedicine systems can be implemented to 

provide monitoring of biomarkers and guide medication adjustments for diseases that do not 

necessarily require regular direct encounters between patient and rheumatologist 30-33 (e.g. gout, postarthroplasty 

rehab). Academic rheumatology programs, through their large patient cohorts, clinical 

research expertise, and potential access to teams of physician extenders can create innovative patient 

management algorithms and communication strategies that preserve rheumatologist time and effort 

for those more complex patients that require direct physician assessment, with application of the 

specialized expertise and “art” of management of patients with lupus, scleroderma, vasculitis and 

November 2012 40


 

 

 

other complex diseases that have become the mainstay of the academic rheumatology clinical practice 

and teaching experience. 

The role of the latest imaging technology in clinical practice within academic medical centers remains 

ill-defined but is a topic that would benefit from attention by the ACR. While use of musculoskeletal 

ultrasound as an adjunct to therapeutic joint injection is increasingly prevalent in private rheumatology 

practices, the implementation of that technique in academic rheumatology practices is in some cases 

inhibited by academic departmental prerogatives, specifically radiology departments that have 

traditionally taken the lead in applying this technique to various clinical situations. At the same time, it 

is expected that rheumatology training programs incorporate the technique and practice of MSUS into 

their curriculum. CORC might help to clarify the optimal and appropriate role of MSUS in rheumatology 

practice and COTW might assist the academic centers by defining the expectable level of training that 

should be a core component of the training programs. Beyond MSUS, other imaging technologies 

continue to provide actionable data helpful to care of rheumatic disease patients. Academic 

rheumatology centers can take the lead in defining the role of the latest MRI techniques in patient 

management. Pre-clinical studies of novel approaches such as use of nanoparticles to image 

inflammation or even provide local delivery of therapeutic agents are promising research topics for 

academic rheumatology programs. 

The concept of personalized medicine is as yet unrealized, but will be a high priority goal and activity of 

academic medicine. The REDCap system through the Clinical and Translational Science programs at 

some academic centers has been useful for building patient-derived data entry programs in a cost 

efficient manner. In addition, PCORI has developed a draft methodology report that provides guidance 

on standards for patient data capture and analysis that may be the “bible” for future research to 

develop a more significant role for the patient in his or her medical care and in defining metrics for 

outcomes. ACR can assist academic rheumatology programs to take full advantage of the resources 

and research funding programs of NIH CTSA and PCORI, as well as other resources that are 

emphasizing the role of the patient in their medical care. The initiatives and research conducted by 

academic rheumatology programs and focused on the clinical challenges presented by patients with 

complex and/or chronic diseases can serve as models for other medical specialties, and gain funding 

and recognition for those academic programs that take the lead in incorporating the latest technology 

into patient-oriented research. 

Rheumatology centers that are able to synthesize their basic, translational and clinical research 

expertise with the expert clinical care of patients with complex rheumatic diseases will assume 

leadership roles. The popular treat-to-target concept is a step toward control of inflammatory arthritis, 

but is not yet able to incorporate in the most informative manner all available clinical, demographic, 

patient-derived and biologic information on a given patient. Research that develops tools for 

identification of the factors that independently predict disease course or outcome would contribute to 

more efficient patient care. Addition of informative predictive biomarkers to the predictive clinical 

November 2012 41


parameters would not only permit estimates of prognosis but could ideally support selection of 

traditional DMARDS vs. biologic therapy in a patient with inflammatory arthritis. A more challenging 

goal, in view of the extreme individual genetic and biologic complexities and variable expression of 

those complexities for every patient, would be a clinical and biomarker-related predictive tool for 

selection of a specific category of biologic drug (i.e. TNF antagonist vs. anti-B cell agent). The COR and 

the research funding mechanisms of the Rheumatology Research Foundation have acknowledged the 

value of prioritizing research with the goal of understanding the individual patient and employing that 

knowledge to optimize the time to remission and the use of healthcare resources. Although the 

pharmaceutical and biotech companies that have conducted large clinical trials and also have strong 

internal research programs that have the potential to make headway in identifying informative 

biomarkers related to therapeutic responses, it is the academic rheumatology programs, in 

collaboration with industry partners and patients and with support from various funding sources, that 

will be eventually successful in achieving the goal of personalized medical care for rheumatic disease 

patients. 

 

Innovative application of educational technology, such as simulation techniques 34 , in rheumatology 

training programs has great potential for achieving educational goals while optimizing time utilization 

by trainees, faculty and patients. Academic rheumatology programs might be encouraged to develop 

such rheumatology-specific applications and to disseminate those resources to other programs, but 

support for development of innovative educational tools might not be among the highest priority goals 

for commitment of College resources at this time. 

3.4.2. Recommendations: New Technologies 

3.4.2.1. Support the development and implementation of tools for incorporation of patientderived 

data into academic medical practices and research. 

 

 

Specific: Goals for the efforts encompassed by this recommendation include: 1) Improved outcomes 

for patients that are most relevant to patient priorities; 2) More time-efficient clinical rheumatology 

practice through increased reliance on the patient to input data; 3) Improved patient management 

through generation of visual demonstrations of therapeutic response most relevant to patients; 4) 

Expansion of relevant clinical data resources to support clinical research studies; 5) Demonstration of 

responsiveness to government priorities regarding the central role of the patient in healthcare; and 6) 

Development of shared resources among academic rheumatology programs 

Measurable: Methods to assess success include documentation of the use of specific data collection 

tools through publications and presentations at the annual meeting, success in research funding 

through PCORI and other agencies, and monitoring of sharing of the most effective patient data 

collection tools across academic centers 

November 2012 42


 

 

 

Attainable: The recommendation is attainable, as several groups have developed patient data 

collection tools 31-33 that are useful for both patient care and research, the Swedish RA registries and 

routine patient care incorporate patient-entered data, and the draft PCORI Methodology Report 

provides guidance on patient-reported data collection approaches 28 . 

Relevant: Patients are the primary focus of clinical care, research and education, and current trends in 

re-design of the healthcare system put increased emphasis on the patient’s role and the outcomes 

most relevant to patients 

Timely: The technology for patient data collection tools is available now, and research funding for 

patient oriented research is available now from PCORI and NIH 

Brief Statement of Strategies and Tactics: The College can promote through existent and developing 

strategies the vision and tools to attain these goals. These include: 

 

 

 

 

Prioritization of patient-derived data for clinical research by COR 

Support for patient-oriented research by the Foundation 

Develop a communication plan for interaction between COR and PCORI 

Attention by RHIT to systems to incorporate patient-derived data into EMR and registry systems 

Resources: Consider dedicated Foundation funds. There is likely to be modest additional staff time for the 

Committee on Research. 

3.4.2.2. Support the development of clinical management tools and systems, including 

multidisciplinary management systems and telemedicine, to improve efficiency and 

outcomes of care, address the limitations and challenges of the current healthcare 

system, and demonstrate the value of academic rheumatology programs. 

 

 

 

Specific: The goals of this recommendation are to: 1) Minimize stress on clinical rheumatology 

practices due to increasing burden of the aging population with chronic diseases; 2) Improve patient 

outcomes by designing the most effective multidisciplinary care; 3) Design systems to achieve tight 

control of inflammatory diseases; 4) Address patient lifestyle needs by facilitating distance disease 

management; and 5) Optimize utilization of physician extenders. 

Measurable: Progress can be formally assessed by: 1) Publication of systematic and multidisciplinary 

disease management systems, and 2) presentations at annual ACR meetings pertinent to 

documentation of tight disease control by academic rheumatology practices 

Attainable: Technology for telemedicine is available. Its value needs to be documented formally 

through research studies. In addition, global management strategies that coordinate care provided by 

multiple healthcare providers in the most appropriate sequence have not been generally implemented 

November 2012 43


 

 

or the approaches agreed upon. Yet the challenges of chronic diseases and limitations of resources 

justify stimulating focus on this goal. 

Relevant: Achieving this goal would improve efficiency of academic rheumatology clinical practice, and 

would demonstrate the capacity of academic rheumatology centers to design high impact innovative 

approaches to healthcare that address significant challenges. 

Timely: The challenges of the current healthcare environment, as well as local time and resource 

limitations of academic rheumatology programs justify this aim. 


strategies the vision and tools to attain these goals. These can include: 

 

 

 

Attention from CORC to multidisciplinary patient management strategies 

Consider having CORC and COR bring together experts in systems analysis and representatives from 

academic rheumatology programs to brainstorm promising systems for coordinated care of patients 

with chronic diseases 

Encourage submissions for studies of patient care involving telemedicine approaches 

Resources: A project proposal for support of a focus group/working group on systems analysis approaches to 

coordinated care would require dedicated resources from the groups identified. 

3.4.2.3. Consider and define the appropriate application of imaging technology in academic 

rheumatology practices and training programs, and support the active contribution of 

academic rheumatology programs to development of new imaging technology to 

improve patient care. 

 

 

 

Specific: Goals of the activities identified in this recommendation are: 1) Determination of the most 

appropriate use and value of incorporation of MSUS in academic rheumatology practices; 2) 

Consideration of how to best navigate the competitive challenges in many academic centers that limit 

incorporation of MSUS in rheumatology practices; 3) Design of the most appropriate curriculum 

focused on imaging techniques for rheumatology training programs; and 4) Encouraging innovative 

research to develop novel imaging technologies for rheumatic disease patient evaluation and 

management 

Measurable: Obtaining data on use, with or without billing, of MSUS in academic rheumatology 

practices. In addition, obtaining data from rheumatology training programs on how they incorporate 

MSUS training, and funding of grants focused on imaging technology. 

Attainable: Because there are political aspects to this goal there is uncertainty regarding extent to 

which MSUS will be successfully incorporated into academic practices. However, COTW and COR can 

track use of imaging in rheumatology programs. 

November 2012 44


 

 

Relevant: Imaging technology is an important adjunct to patient care and needs to be incorporated in 

the most appropriate yet evidence-based manner. In addition, imaging technology can provide an 

important revenue stream for rheumatology programs, to the extent that they can capture that 

revenue 

Timely: If academic rheumatology practices do not take at least partial ownership of implementing 

imaging into clinical care, they will have missed an opportunity. 


strategies the vision and tools to attain these goals. These may include: 

 

 

 

Documentation by CORC of use of and billing for MSUS in academic rheumatology practices 

Development by COTW of imaging curriculum for training programs 

COR and Foundation encourage research on novel imaging technologies 

Resources: Dedicated staff and volunteer time in the areas of socioeconomic affairs, education, research and 

training, and the Foundation will be needed. 

3.4.2.4. Encourage and support research aimed at development of predictive tools, including 

clinical, demographic, patient-derived and biologic parameters, to improve patient 

management. 

 

 

 

 

Specific: The goals encompassed by this recommendation include: 1) Improved outcomes for patients; 

2) Improved patient compliance and engagement; 3) Increased efficiency of academic (and nonacademic) 

rheumatology practices; 4) More effective utilization and targeting of available therapeutic 

options; 5) Effective collaboration between academic rheumatology centers and industry partners; 

and 6) Growth in funding of translational research led by academic rheumatology programs 

Measurable: Success can be assessed through publication and presentation of validated prediction 

tools, and successful funding for research studies aimed at development of predictive tools and 

biomarkers. 

Attainable: This is a challenging but potentially attainable goal. Awareness and application of the 

newest bioinformatics approaches, including those developed for analysis of large genetic and genomic 

research datasets can facilitate success. In addition, advances in understanding the 

immunopathogenesis of rheumatic diseases, along with the generation of large datasets (genetic, gene 

expression, proteomics, etc.) provide data ripe for analysis in biomarker research. 

Relevant: Development of predictive tools for diseases such as rheumatoid arthritis or lupus would 

have a major impact on efficient and effective patient management and outcomes. In addition, 

development of informative biomarkers by academic rheumatology centers would likely bring in grant 

November 2012 45


 

support, might establish intellectual property generating sustained revenue and would provide a basis 

for high profile demonstration of the value of academic rheumatology 

Timely: Predictive tools are needed; the biology and information technology support may be sufficient 

to support success. 

Brief Statement of Strategies and Tactics: The American College of Rheumatology can promote through 

existent and developing strategies the vision and tools to attain these goals. These can include: 

 

 

COR can aggregate information on bioinformatics tools and statistical approaches to analysis of large 

datasets for the benefit of research conducted by its members 

COR and the Foundation can encourage and fund research focused on development of predictive 

clinical tools and biomarkers 

Resources: Dedicated staff and volunteer time in the research and training and the Foundation, as well as 

dedicated funds from the Foundation for research grants. 

November 2012 46


3.5. Expansion and cross-disciplinary integration of clinical data infrastructure. 


 

 

 

 

The growing complexity of all areas of medicine and the continuing rapid development of new 

knowledge impacts all physicians and practices. Certainly this is true in Rheumatology with basic and 

clinical research on the immune system, among other fields of science relevant to the rheumatic 

diseases, and the myriad of complex diseases that rheumatology professionals treat. In addition, the 

importance of demonstrating that rheumatologists provide quality care that is patient centered and 

efficient, as embodied in the quality movement over the past decade or more, also impacts the need 

for integrating various tools such as electronic medical records, registries and other databases. 

Academic medical centers are large and extremely complex organizations. With missions such as 

teaching and research that extend beyond providing clinical care, the need for robust data integration 

is great. Academic divisions are looked upon to create new knowledge through basic, clinical and 

translational research that can be effectively and rapidly translated into improved clinical care for our 

patients. 

Electronic medical record (EMR) use is prevalent in academic rheumatology centers (>70%). However, 

many of these are “generic”, and not specifically designed for the rheumatology practice. This is due in 

large part to the fact that the academic divisions and departments are often not in control of their own 

practices, as institutions make decisions about choosing between different information technology 

options. The ACR Benchmark survey indicates that the EMR is heavily used for test ordering. The EMR 

is integrated with registries in approximately 30% of cases. It is used to update medication lists in 

nearly 90% of practices overall, and is used for staff communications and patient communications. 

There is no uniformity in the way medical information, particularly rheumatology relevant information, 

is gathered. A further major problem is that there are a number of different EMR platforms used at 

different institutions which today cannot be linked to each other. As a result, potential solutions that 

may have been developed using a particular EMR or registry and disseminated through abstracts and 

the medical literature, or by comparing best practices, may not be available if the institution has 

chosen a different platform. 

Ideally the expansion and cross-disciplinary integration of data would serve multiple functions in an 

efficient, user friendly manner with the ability to continuously improve as new technologies and 

solutions become available. Too often, academic centers operate as independent silos, each inventing 

their own solutions to problems and challenges, resulting in decreased global efficiency. Solutions to 

this are not unprecedented at the national level. The NIH utilizes national and regional cores to 

integrate and synergize the research efforts of individual CTSA units. Similarly, in the clinical sector, 

the Office of National Coordinator of Health Information Technology (ONCHIT) is tasked with certifying 

EHR programs and developing compatibility standards. More specifically, their initiatives parallel our 

November 2012 47


own desires: cyber security, nationwide health information networks and clinical decision support 35 . 

Although in their infancy, these programs and similar state and regional efforts would allow clinical 

data, with disease registries either embedded within the electronic medical record or with excellent 

interfaces between systems, to interface with research applications and application to point of care 

reminders in order to measure and drive clinical quality improvement. These might also link to 

applications such as maintenance of certification and licensure. These solutions must constantly look 

at and solve administrative burden issues. None of this is easy, but it is essential to drive innovations 

that improve care without putting continuous additional burdens on rheumatologists and other 

members of the care team in an already strained workforce. 

3.5.2. Recommendations: Clinical Data Infrastructure 

3.5.2.1. Continue significant investment in Registries and Health Information Technologies 

The panel recommends that the College continue to invest heavily in the structure and function of the Registry 

and Health Information Technologies department and corresponding committee (RHIT). The committee, as 

one of its charges, should specifically address the challenges and opportunities that exist with expansion and 

cross-disciplinary integration of clinical data infrastructure in academic rheumatology. In collaboration with 

the QOC and CORC, it should quickly translate new measures of process and outcomes into the RCR and 

partnering EMR entities, including point of care reminders, guidelines and disease management instruments. 

It should also partner with the Committee on Research regarding emerging options such as expanded 

biomarker registries and outcomes research. 

 

 

Specific: The goals of the recommendation in this aim are: 1) Improved care across the continuum of 

rheumatologic disease care by the use of expanded and integrated information technology; 2) 

Improved efficiency of the academic clinical practice; 3) Rapid transfer of new knowledge gained from 

research to patient care by innovative technological solutions; 4) Providing the current and future 

Rheumatology workforce with new tools and knowledge about how to use them; 5) Assisting academic 

practices in demonstrating their value by utilizing technology for measurement and reporting to 

internal and external stakeholders (the institution, CMS, third party payers, etc.); 6) Developing 

support services that academic units and others can utilize to share best practices; and 7) It is 

acknowledged that physician time is the most expensive resource, so academic centers are best served 

by developing and expanding data infrastructure to drive efficiencies; 

Measurable: Success in this recommendation can be assessed using: 1) Disease outcomes metrics 

including cost effectiveness, patient satisfaction with care, treating to target, patient safety, remission 

or low disease state, etc.; 2) Provider satisfaction based on ability to measure processes and outcomes 

easily, and more efficiently; 3) Growth of the rheumatology division portfolio based on growth of 

November 2012 48


 

 

 

practice due to efficiencies, growth of grants based on measurable and retrievable research data, 

meeting external demands (reporting parameters such as EMR adoption, E-prescribing, meaningful 

use); 4) Cost savings and cost recovery attributable to the implementation of these measures; 5) The 

number of academic units that connect with RISE or other registries; and 6) Measures of utilization 

(listserv subscriptions, web traffic, call volume) of new support services. 

Attainable: The RCR already exists and can be utilized, and RISE is under development. EMR utilization 

in academic rheumatology centers is prevalent (>70%) and examples linked with registries exist. There 

has been and continues to be ongoing innovation in optimizing EMRs and registries (see recent ASM 

abstracts in the Clinical Quality and Innovation arena). PQRS has proven that use of registries and other 

technology can allow either bonuses for, or prevent penalties associated with reporting quality 

measures. 

Relevant: Academic rheumatology divisions and the academic workforce in general are under financial 

and productivity strain. Expanding data infrastructure will allow for revenue growth, efficiencies, a 

more satisfied workforce and demonstration of the value of the academic division. Technology exists 

and is expanding rapidly to allow for more robust information technology solutions. In addition, 

meaningful use stage II requirements include reporting to a specialty registry and reporting on clinical 

quality measures, all of which could be satisfied through the registry. 

Timely: Academic centers see the most complex tertiary and quaternary patients. They expect, and 

internal and external stakeholders demand, excellent care in line with the IOM’s Six Aims 36 . It is 

impossible to improve what isn’t measured, and it must be done in a cross disciplinary and efficient 

manner. In addition, as part of the Affordable Care Act 37 , over the next several years there will be 

increasing demands, and in fact already planned potential financial penalties, for non-reporting of 

required information to the Centers for Medicare and Medicaid Services. With affordable care 

organizations and other innovative payment models, revenue will also be at risk if the technology to 

measure processes, outcomes, and efficiencies of care is not harnessed. Finally, the College has 

acknowledged the importance of this area by its substantial investment in quality measurement, 

development of the RCR, and formation of the RHIT Committee. 

Brief Statement of Strategies and Tactics: 

 

 

 

 

 

Continued investment in the structure and function of the RHIT Committee 

Expansion of registry portfolio 

Dashboard or toolbox of resources for academic division to shorten timelines, improve efficiencies, 

share best practices, demonstrate value to internal and external stakeholders 

Expansion of online resources to share best practices 

Utilize gatherings of Division Directors and Fellowship Directors at the annual meeting to share 

advances in clinical data infrastructure 

November 2012 49


Resources: It is expected that volunteer and staff time in the areas of RHIT, QOC, and CORC will be needed. 

Further development of specific technologies identified may require financial commitments (such as 

expansion of RCR, other planned registries) 

November 2012 50


3.6. Regulatory burdens within the clinical and scientific enterprise 


 

 

Regulatory burdens as a major component of administrative activities negatively impact all missions of 

academic Divisions of Rheumatology, including research, education, and clinical practice. 

Demonstrating compliance with an increasing number of regulations adds work hours and frustration 

to academic faculty and their staff. In 1997, Jordan J. Cohen, MD, President of AAMC, noted that 

“increasing the administrative burden of meeting expanding regulatory and reporting requirements” 

threatened academic medicine 38 . Since that time, the regulatory requirements have only increased. 

The ACR Benchmark Survey from May 30, 2012 noted that administrative duties accounted for more 

than 10% of time for 48.1% of the academic workforce 4 . 

In the research arena, a comprehensive survey was completed by the Federal Demonstration 

Partnership (FDP), a cooperative initiative among ten federal agencies (including the NIH and NSF) and 

approximately one hundred institutions that receive federal funds. The FDP was established in 1988, 

and its purpose is to streamline the administration of federally sponsored research. The faculty 

administrative burden survey was carried out by the Faculty Standing Committee on the FDP and the 

report was made public in January 2007 39 . In addition to “direct” research activities, faculty 

researchers also undertake activities that enable and support their research projects, which includes 

complying with institutional rules and State and Federal laws that govern research (e.g., rules 

governing research on human subjects, using and care of animal subjects, safe handling of hazardous 

material). When research is supported by federal funds, faculty researchers commit to additional tasks 

intended to guarantee effective use and stewardship of those funds, such as writing periodic scientific 

progress reports, providing financial reports, and certifying the effort of research participants. There 

“indirect” research activities that ensure compliance with applicable rules, regulations, and policies are 

essential for the safety and welfare of research participants, sponsors, and the public. However, they 

constitute a set of burdens on researchers that, if not handled efficiently, can diminish the time 

available for the research itself. Key results of this report include: 

o Of the time that faculty committed to federal research, 42% was devoted to pre- and postaward 

administrative activities, not to active research. 

o Particularly burdensome were IRB compliance issues, HIPAA compliance issues, and IACUC 

protocols, training and compliance issues. 

o 95% of respondents believed that they could devote additional time to active research if they 

had more assistance with research-related administrative tasks. 

o 76% of respondents were willing to reallocate direct costs to provide for research-required 

administrative support. 

November 2012 51


 

 

 

 

o The time required to complete administrative tasks is a result of federal agency and local 

institutional policies, procedures, and systems. 

o Many tasks should be streamlined or made uniform across institutions and federal funding 

agencies in order to lower the time required for completion. 

o 83.6% agreed that administrative burden associated with federally funded grants has increased 

in recent years. 

o As compared with Full Professors, Assistant and Associate Professors rated regulatory 

compliance as more burdensome. 

o Women and minority investigators also rated regulatory compliance as more burdensome than 

do men and non-minority investigators. 

The data from the survey clearly show that the level of administrative burden is high enough to 

routinely take scientists away from their research for significant amounts of time and that the problem 

may be increasing given new regulations since 2007. 

HIPAA regulations specifically impact research in the areas of stored tissue and genetic databases, data 

warehouses, and community research. The AAHC recommended 40 that HIPAA be revised to allow it to 

defer the Common Rule in matters of protecting the privacy of protected health information of 

research participants. Existing Common Rule guidelines already protect health information. They also 

suggest that a national genetic privacy act should be implemented in a revision of HIPAA to resolve the 

current conflicts and confusion over differences between state genetic privacy acts and HIPAA that 

hamper tissue bank and genetic dataset research. 

Smith, et al. 41 state that “quantifying the monetary and productivity costs of regulations is often 

difficult. Whereas the cost of each individual regulation may not appear to be significant, the real 

problem is the gradual, ever-increasing growth or stacking of regulations.” Increasing regulatory 

burdens are occurring during a period of severe financial pressure, and recovery of costs is determined 

by rules set by the White House Office of Management and Budget which restricts reimbursement to 

Universities by the federal government. This report identifies relatively few categories of solutions: 

o Eliminate outright or exempt universities from the regulation 

o Harmonize the regulation across agencies to avoid duplication and redundancy 

o Tier the regulation to levels of risk rather than assuming that one size fits all 

o Refocus the regulation on performance-based goals rather than on process 

o Adjust the regulation to better fit the academic research environment 

In January 2011, President Obama released Executive Order 13563 “Improving Regulation and 

Regulatory Review” 42 , along with two presidential memoranda focused on regulation 43,44 . These 

documents require federal agencies to develop plans for regulatory review to ensure that regulations 

become more effective and less burdensome. However, higher education has largely been absent from 

recent governmental discussions of regulatory reform, despite evidence contained in a report prepared 

November 2012 52


for the US Commission on the Future of Higher Education that “there may already be more federal 

regulation of higher education that in most other industries 45 .” 

 

 

 

 

 

New NIH guidelines on conflict of interest 46 (COI) are set to be implemented by institutions receiving 

grants from the Public Health Service (PHS) and will further increase administrative burdens on the 

faculty. The PHS Final Rule (42 CFR Part 50) requires that all faculty conducting PHS-funded research 

complete an annual Financial Disclosure Statement and places the burden of reviewing the information 

and developing/implementing a management plan on the institution. Any investigator who does not 

complete the disclosure and education will not be permitted to submit a proposal to PHS or continue 

working on a funded grant beyond that date. Of course, managing COI is an important issue to assure 

public trust in federally-funded research. However, this places additional unfunded administrative and 

regulatory burdens on faculty and institutions. 

The ACGME approach to certifying that clinicians are prepared to enter clinical practice in their 

specialty or subspecialty area of medicine is currently focused on the reporting of program 

requirements. As recently reported in the New England Journal of Medicine resident duty hour 

regulations developed by the ACGME went into effect in July 2003 47 and were preceded by much 

debate among medical educators. The regulations have forced change in the structure of many 

residency programs and all programs have been forced to re-evaluate the structure of patient care 

systems in the academic setting. Program directors are faced with a new layer of administrative burden 

in providing documentation of compliance with the regulations. Fortunately, rheumatology fellowships 

are not severely impacted by this particular regulatory burden at the current time due to the nature of 

the specialty, but in the rapidly expanding regulatory climate continue to be at risk. 

In a recent New England Journal of Medicine article, authors outlined the New Accreditation System, 

which will go into effect for Internal Medicine subspecialties in 2014 48 . The new system will require 

training programs to report on to be determined benchmarks. It is critical that the College lead the 

efforts to establish these benchmarks in a proactive manner rather than react to increased regulatory 

burdens. 

Maintenance of Certification (recertification) promotes lifelong learning and the enhancement of the 

clinical judgment and skills essential for high quality patient care. Rheumatologists certified in or after 

1990 renew their certificates through ABIM's Maintenance of Certification program. In addition to 

sitting for the exam, ABIM requires completion of self-evaluation in medical knowledge and practice 

performance 49 . 

Regulations around incentives for reporting of clinical quality measures (CQM) through electronic 

health records (EHR) will increase regulatory burdens for academic clinical practices. In July 2010, the 

Centers of Medicare & Medicaid Services (CMS) published a final rule 50 which established three phases 

of the EHR Incentive Program. (1) The use of a certified EHR in a meaningful manner. (2) The electronic 

exchange of health information to improve quality of health care. (3) The use of certified EHR 

technology to submit clinical quality and other measure. CMS defines CQM as the “tools that help us 

November 2012 53


measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure 

and/or systems that are associated with the ability to provide high-quality health care and/or that 

relate to one or more quality goals for health care.” 

3.6.2. Recommendations: Regulatory Burdens 

3.6.2.1. Collaborate with other organizations to understand and support current activities that 

would lower research regulations at academic centers. 

The COR should develop a strategy to engage with the Federal Demonstration Partnership, the 

American Association of Universities, the Clinical and Translational Science Award (CTSA) consortium, 

and other umbrella organizations to understand the current activities that would lower research 

regulations at Universities. Charge COR to engage other standing committees, such as the GAC, that 

may be able to address the issue. 

 

 

 

 

 

Specific: Improved understanding of the ongoing national efforts to reduce regulatory burdens 

associated with research. Develop a strategy to understand these issues and contribute to solutions in 

conjunction with other professional and volunteer organizations. 

Measurable: Contacts and participation with outside organizations and ability to gain insights into their 

efforts from the perspective of academic rheumatology. 

Attainable: Engagement with the process should be attainable but the ability of the College to impact 

the ultimate policy and regulatory decisions is not clear. 

Relevant: Regulatory burdens dramatically reduce the time academic scientists participate in the 

conduct of research. 

Timely: There are a number of national efforts directed at reducing regulatory burdens imposed by 

federal regulations and institutional rules. At a national level, there are stated goals articulated in 

presidential orders to reduce regulatory burdens, but research universities have been absent from the 

discussion. 

Brief Statement of Strategies and Tactics: Identify and contact representatives of national organizations 

working to reduce regulatory burden. Understand the initiatives that are in place and determine how the ACR 

can or should contribute to these efforts. 

Resources: Staff time will be required to perform the work described above. A volunteer from COR will need 

to assist with professional interactions. 

November 2012 54


3.6.2.2. Ensure organizational accountability with respect to following best practices in 

administration of programs 

 

 

 

 

 

Specific: This recommendation is intended to ensure that programs managed by our organization 

create a positive, burden-free experience for the participants (our members). An audit of all ACR 

program administration procedures is necessary to ensure streamlined procedures (e.g., volunteer 

nominations, awards of distinction, FIT scholarship, etc.); however this is particularly important for our 

Foundation programs, to allow investigators to spend their time on direct research activities rather 

than indirect activities that add to administrative burdens. 

Measurable: While it is essential to ensure quality control and obtain information needed to make 

appropriate decisions and selections, the types and frequency of contacts should have concrete goals. 

The time for completion of administrative tasks should be assessed by the Committees and Councils 

responsible for each program, and/or a small focus group of participants. 

Attainable: The College has control over administration of its programs, so achieving this goal is 

attainable. 

Relevant: This goal is relevant because it assures that our own organization does not contribute to the 

overall burden of regulation. 

Timely: This recommendation is in conjunction with our overall goal to reduce regulatory burdens that 

impact time and stress associated with rheumatology career development. 

Brief Statement of Strategies and Tactics: Charge the Foundation’s Scientific Advisory Council with a careful 

review of the administrative activities associated with the awards portfolio and assure that there is no excess 

burden beyond what is necessary to assure success of grantees and of the portfolio. This review should 

include a thoughtful audit of the current policies and procedures, reporting requirements and templates, etc. 

Resources: Achieving this outcome will require minimal time from Foundation staff and volunteers. 

3.6.2.3. Develop a comprehensive strategy to address new ACGME reporting requirements. 

 

 

 

Specific: This recommendation targets the need for the ACR to contribute to the development of our 

own educational standards and metrics. 

Measurable: The deliverable product of this recommendation is approval by ACGME of suggested 

specialty-specific measures of competency. 

Attainable: The ACR has established a good working relationship with the ACGME, and the COTW 

(Committee on Training and Workforce) has already begun work in this area. 

November 2012 55


 

 

Relevant: This process is meant to assure that all relevant resources of the ACR are utilized to achieve 

the goals of the organization with regard to academic rheumatology and serve the members of the 

college by establishing the reporting standards for the specialty. 

Timely: With changes in ACGME reporting requirements on the horizon in the next 12-24 months, the 

ACR must be proactive in setting the standards for the specialty. 

Brief Statement of Strategies and Tactics: COTW will be proactive in development of new ACGME milestones 

and provide format/template for rheumatology training programs to assist with upcoming changes in program 

reporting requirements. 

The COTW has been working closely with Dr. Jerry Vasilias, Executive Director of the Review Committee for 

Internal Medicine, Accreditation Council for Graduate Medical Education, and will maintain communications 

with the program directors throughout the process as the ACGME/RC-IM communicate their expectations 

specifically regarding the development of milestones for rheumatology. The committee plans to establish a 

panel to address the new accreditation system with regard to the rheumatology milestones. It will also be 

important to engage the clinician scholar educators in this process. 

There is still some confusion about expectations for reporting because rheumatology program directors may 

be receiving a different message from their core programs. However, ACGME has made it clear that the 

development of ACGME/ABIM milestones for rheumatology has not officially begun. When work in this area 

does begin (in the future), ACGME and ABIM will contact the ACR and ask the leadership to recommend 

individuals to participate in this initiative. Milestones for the subspecialties will not be available when the RC- 

IM transitions into the NAS in 2013. Milestones for all of the subspecialties of IM will be developed and 

introduced at some point in the future. This transition will allow the ACGME and the ABIM (the partners in the 

Milestones venture) to solicit the input and wisdom of the education leaders in the subspecialty communities 

to develop the subspecialty-specific milestones. 

Resources: Achieving this outcome will require additional, or refocused, volunteer and staff time from COTW. 

3.6.2.4. Ensure that academic rheumatologists may efficiently complete maintenance of 

certification programs. 

 

 

Specific: This recommendation specifically targets the College’s MOC efforts. It is imperative that the 

college continue programs through the Committee on Education that enable efficient MOC. Offering 

ABIM recognized review courses and practice improvement modules is extremely important. 

Measurable: The numbers of offerings and the ability of members that utilize these resources is a 

measurable outcome. 

November 2012 56


 

Attainable: This recommendation is not a “stretch” goal, but reaffirms the importance of activities that 

reduce the burdens associated with maintenance of certification. 

Relevant: As academic rheumatologists are responsible for training students, residents, and fellows it is 

essential that all faculty maintain their clinical knowledge and their understanding of practice 

improvement. 

Timely: Ongoing revisions in the maintenance of certification process require that the College continue 

its strong association with ABIM and the ABIM-Rheumatology board. 

Brief Statement of Strategies and Tactics: The COE will continue to plan and offer specific courses that meet 

ABIM requirement, continually update the PIM, and assure that academic rheumatologists are aware of 

resources that can assist with maintenance of certification. 

Resources: This is an ongoing activity of COE so no additional new resources will be required. 

3.6.2.5. Assure consideration for the inclusion of academic clinical practices in Registry and 

Practice work plans to assist with implementation of reporting requirements. 

• Specific: The RCR now enables practitioners in all venues to complete their PQRS reporting 

requirements. This effort may not have substantial impact on academic clinical practices because these 

systems are available in house at these facilities. However, more importantly, the registry will enable 

tracking of quality of care, which, when needed in the future, will be an asset to participating clinical 

practices, including academic practices. 

• Measurable: Can track the proportion of participating sites utilizing the registry for quality of care 

reporting. 

• Attainable: Can be integrated into existing efforts, with understanding that success will depend on ease 

of connectivity and use and ready access to data for this purpose. 

• Relevant: Quality of care is also part of the ACGME mandated curriculum for fellowship training, which 

could be facilitated by the registry. The ACR could also monitor the number of training programs 

whose fellows use the registry to meet their curriculum requirements in the area of quality of care. 

Timely: Full implementation of the registry will assist clinical practices and training programs in 

meeting these administrative requirements. 

Brief Statement of Strategies and Tactics: These efforts should be integrated into existing activities of CORC 

and RHIT. 

Resources: Minimal time and effort from staff and committee members in the areas named above. 

November 2012 57


3.7. Workforce development across all domains, including expansion of the quality and quantity of 

fellowship pool, better integration of PhD faculty into academic rheumatology and the College, and 

enhanced training of nurse practitioners and physician’s assistants leading to efficient incorporation of 

these health professionals into both academic clinical care and rheumatology community practice 

settings. 


 

 

 

 

 

 

There is an increasing demand for health care professionals with specialized training to attend to the 

medical needs of the estimated 84 million Americans afflicted by a rheumatic disease or poor bone 

health 51 . Unfortunately, there is not an adequate supply of physicians and health professionals to meet 

this demand. 

The rheumatology workforce shortage is based not only on the increased needs of an aging population, 

but also on the changing demographics of the rheumatology workforce, including age distribution, 

gender trends, shifting expectations regarding workload and hours, and the impending retirement of a 

large segment 4 of providers.. 

Insightful academic benchmark data have been acquired recently, resulting in recommendations for 

continued analysis and specific projects 3-7 . However, many of the recommendations have not yet been 

acted upon, and there is as yet little quantitative understanding of the expected impact on the 

academic rheumatology community over the next 10-15 years. An aging work force and a stagnant 

number of trainees currently in academic training programs have the potential to result in a profound 

limitation of access to care. 

Current projects such as Choose Rheumatology and student outreach events at the Annual Meeting 

have recently been implemented through the COTW; however it is crucial that the College increase its 

efforts to recruit qualified individuals to the specialty 52 , and dedicate the resources necessary to grow 

and develop the workforce to sustain the future of rheumatology. 

Despite the potential to add to the diversity and quality of the workforce, international trainees often 

are required to leave the country after the completion of training. Several professional groups are 

already proposing new policies to retain these types of individuals within the US workforce as a means 

to improve the quality and scientific impact of the US academic faculty pipeline 15 . Similar steps might 

be beneficial to rheumatology as well. 

In addition to the issues noted above, in recent years funding of residents through Medicaid has been 

withdrawn, the financial security of rheumatology and especially pediatric rheumatology divisions has 

eroded, and institutional support for subspecialty training has diminished. In parallel, the number of 

open training positions has remained substantial, most likely due to limitations in available funds 53 . 

Funding shortfalls for rheumatology training have also been significantly exacerbated by funding 

November 2012 58


 

 

 

 

 

allocation shifts at the NIH. Thus, the success rates for individual and institutional NIH Fellow Training 

(F and T grants, respectively) and career development (K) grants have declined from over 50% to 

around 30% for NIAMS, with concurrent declines at other institutes important to academic 

rheumatology such as NIAID. Similarly, the funding of rheumatology research is threatened. Despite 

the flat NIH budget, total funding for research defined as “arthritis” is actually dropping, and the effect 

of that change on research capabilities is additionally magnified by inflation and mandated salary 

increases for technical research staff as well as artificial PI salary caps. These trends increase the 

potential for established investigators to change career paths and in some cases join industry, resulting 

in a decline of researchers and educators available as teachers and mentors for the future workforce. 

With increases in complexity of tools used for the assessment of patients with rheumatic diseases, 

education of trainees becomes more complex and time consuming, thus difficult to perform in 

academic rheumatology centers that are challenged by augmented pressures to increase clinical 

income. 

It is imperative that the College work to increase awareness of the need for support for adult and 

pediatric rheumatology training, and to aggressively advocate for increased support for such training 

from governmental agencies and health care institutions. 

As the specialty of rheumatology faces these mounting challenges, it also faces rapidly expanding 

science, leading to new research and clinical care opportunities in a broad array of disciplines. These 

areas include immunotherapeutics, autoimmunity, autoinflammatory diseases, bone biology, 

osteoimmunology, pulmonary biology, mucosal immunology, pain medicine, musculoskeletal 

ultrasound imaging and many others. This expansion provides new opportunities for sub-specialization 

within rheumatology, a process which may draw new individuals into the field. This also demands the 

availability of highly trained and specialized educators who can effectively teach across a wide 

spectrum of domains, ranging from the interpretation of novel genetic tests to the use of ultrasound 

and other advanced imaging tools. 

With specific regard to academic rheumatology clinical practices, reimbursement rates 54 often do not 

hold pace with the expenses of physician-delivered medical care. Economic pressures as well as the 

increasing demand for patient care services point to better utilization of mid-level providers (MLP), i.e. 

Physician Assistants (PAs), Nurse Practitioners (NPs) and Advanced Practice Nurses (APN). Currently, 

these segments are the fastest growing areas within the ARHP membership, and are expected to play 

more prominent roles in both academic and community practices. The College has developed a 

comprehensive course for practitioners in adult and pediatric rheumatology, but has not yet 

constructed a formal training program for these providers. 

Another area of potential growth and integration within the rheumatology workforce is PhD scientists. 

These individuals are the lifeblood of academic divisions 55,56 and necessary for the future success of 

academic rheumatology. However, these individuals are often not eligible for independent research 

November 2012 59


funding and are not fully integrated into academic divisions across the country. Funding their positions 

remains a challenge, and their contributions require innovative solutions to this complex issue. 

 

The panel strongly recommends the College lead the way in establishing best practices for 

incorporating clinical and scientific health professionals into academic rheumatology units, 

rheumatology practices and the organizational structure of the College (e.g., service and leadership 

opportunities). 

3.7.2. Recommendations: Workforce Development 

3.7.2.1. Collect annual data to assist with decision making concerning the needs of training 

and workforce development. 

 

Specific: This goal speaks to our need to increase our knowledge about the status and needs of the 

adult and pediatric rheumatology workforce on a more regular basis. 

Measurable: Data should include measurables such as: 

o Number and types (MD, MD-PhD, PhD, MLP) of trainees entering programs, as well as attrition 

and reasons (e.g., international medical graduates returning to their home country, career 

shifts to industry, etc.) 

o Number of filled, unfilled and inactive trainee, MLP and junior faculty positions 

o Barriers to sub-specialty fellow training (e.g., financial, quality of candidates) 

o Division’s funding sources for trainees 

• Attainable: Existing survey tools could be re-evaluated and modified, or new tools developed to 

capture needed workforce data, including gender and race and ethnicity. 

• Relevant: The number of health care providers (physician and non-physician) desperately needs to be 

increased 

• Timely: Data could be collected annually in July or August (after traditional end of a fellowship training 

year). The goal of acquiring and analyzing the first data set should be achievable within 1 year, and 

then the process should be supported annually to understand changes over time. Ideally this process 

would be integrated with other data collection mechanisms within the College (e.g., benchmarking 

survey, CRM membership database). 

Brief Statement of Strategies and Tactics: The panel recommends that the College conduct an annual 

survey of program directors and division directors to gather data to assist with up-to-date assessment of 

the training landscape. This information is necessary to enable the College to rapidly adjust funding and 

lobbying strategies in support of sub-specialty training. The data obtained will help monitor financial issues 

around fellowship training. The data will not only assist the educational mandate of the College but also 

November 2012 60


provide data in support of requesting more federal support for rheumatology training. These data are 

especially important in the upcoming years, i.e. during the implementation of the Affordable Care Act. 

Resources: Staff and volunteer time in the socioeconomic affairs and research and training departments to 

modify or develop survey tools to effectively track the needs and activities of the academic rheumatology 

community and create programs and recommendations to make the needed changes. Staff and volunteer 

time in the government affairs department would also be required to increase advocacy focused on key 

issues identified from the data collected 

3.7.2.2. Increase funding for adult and pediatric rheumatology workforce development. 

• Specific: 

o Increase funding for individual fellowship slots to a level closer to the full amount (rough 

estimates are at least $55,000 per year) 

o Reconsider in special circumstances the requirement for institutional support as a prerequisite 

for training support 

o Reconsider the Foundation’s citizenship requirements for awards and grants 

o Increase advocacy to assist divisions to increase institutional support for fellowship programs, 

including training in research 

o Newly implement the financial support of training of adult and pediatric MLP and RN’s as well 

as other rheumatology allied health professionals 

• Measurable: Increase the number of trainees entering adult and pediatric trainings programs by 20% 

o Number of graduating trainees from adult and pediatric trainings by 20% 

o Decreased number of unfilled trainings slots due to lack of funding by 50% 

o Increased number of MLP within rheumatology by 25% (baseline 2013) 

• Attainable: Historical data attests to the benefits of increased support for training in rheumatology. 

This goal is highly relevant to academic rheumatology and to the supply of rheumatologists for 

community practice. 

• Relevant: Increased numbers of trainees and assistance with patient care by MLP will increase the 

work force in academic rheumatology in order to meet increasing demands for clinical care. 

• Timely: The goal of acquiring and analyzing the first data set should be achievable within 1 year, and 

then the process should be supported annually to understand changes over time. 

Brief Statement of Strategies and Tactics: The panel recommends that the College and Foundation commit 

even more attention and resources to the training of rheumatology health care professionals over the next 5 

years. Such an effort will not only give the College an opportunity to help meet the expanding demand for 

care of patients with rheumatic disease, but will also firmly establish the role of the College in defining the 

quality and value of rheumatology MLP in parallel with its commitment to rheumatology fellowship training. 

November 2012 61


Resources: A substantial increase in funds directed to training initiatives will be required. 

3.7.2.3. Increase efforts aimed at increasing the rheumatology workforce and limiting 

workforce attrition. 

Factors that lead to workforce attrition need to be defined, measured and mitigated. The College may be 

able to play a more active role, in partnership with academic rheumatology units, in application for 

permanent visa status for individuals whose training has been supported by the Rheumatology Research 

Foundation. Successful career models that allow part time academic work during years of increased 

commitment to child care responsibilities need to be nurtured and disseminated. Strategies to assist 

researchers through bottleneck career transition stages, potentially requiring new funding mechanisms, 

could mitigate attrition of rheumatology researchers, and need to be tested. 

• Specific: This goal is aimed at identifying barriers to sustaining a career in academic rheumatology. 

• Measurable: A total of no more than 230 trainees complete adult or pediatric rheumatology training 

programs each year, and the panel is proposing that this number be increased to 280 over 5 years. This 

goal may also be measured by the following: 

o A measurable increase in the number of IMGs who stay in the US , despite initial limitations of 

their visa status 

o A measurable decrease in the number of rheumatology faculty leaving academic rheumatology 

positions 

• Attainable: With increased attention on retaining IMGs, reducing attrition within academic 

rheumatology, and focusing funds on increased training, this goal is attainable. 

• Relevant: This goal is particularly relevant as rheumatology faces a workforce shortage that will lead to 

issues with patient access. 

• Timely: Given the shortage of academic rheumatologists and the remarkable proportion of IMGs in 

rheumatology trainings programs, the timeliness is clear. 

Brief Statement of Strategies and Tactics: The panel recommends that the College increase its focus on 

limiting attrition of academic rheumatologists, especially to other countries or to non-rheumatology 

professional pursuits. This envisages a more proactive role of the College in maintenance of the 

rheumatology workforce, and involvement in career development across a continuum, ranging from 

before commencement of fellowship through early and even mid-career transition points. 

Resources: This effort would require a modest incremental increase in staff support, as well as limited 

funds for new career development programs. The COTW will have a primary role in this effort. 

Engagement with the Foundation will be essential in connection with eliminating any barriers to career 

development funding that are based on citizenship status. 

November 2012 62


3.7.2.4. Increase the support of adult and pediatric rheumatology units in providing 

specialized training for physicians and mid-level providers. 

 

 

 

 

 

Specific: Given the expanding scope of the specialty, greater involvement of the College is needed 

for development and teaching of components of the core curriculum for trainees. This includes, but 

is not limited to, bone biology, immunology, clinical research training, ultrasound, and pain biology 

and treatment. Recertification courses are needed for pediatric as well as adult rheumatologists. 

Provision of certification courses for both adult and pediatric MLP is important. At present, some of 

these modules have been developed; however completion does not provide formal certification. 

Measurable: Outcomes of this recommendation are measurable, based on development of the 

specific programs, and the suggested timetable for each: 

o Develop a pediatric rheumatology certification course (suggested timetable - late 2014) 

o Finalize adult and pediatric rheumatology ultrasound training modules and certification 

courses (suggested timetable - by mid to late 2014) 

o Develop new modules for the Advanced Course in Rheumatology and The Fundamental 

Course in Rheumatology - for adult and pediatric rheumatology (suggested timetable – mid 

to late 2014) 

o Develop web-based modules containing training content that can be effectively taught in all 

rheumatology training programs. This would include materials for initial certification and 

recertification. 

Attainable: Given the scope of the above mentioned activities and that many of them are in 

development or have been developed in their first phases, the time frame is both realistic and 

appropriate. 

Relevant: To maintain/enhance the quality of training and allow divisions with large patient 

population volumes and those with poor reimbursement profiles the time for training, the central 

provision of teaching modules for training and certification of physician level and allied health 

professionals will add value. 

Timely: The timeliness is clear and has been demonstrated throughout this section. Although the 

AHRP has done much to address this issue, the training of non-physician providers in rheumatology 

is still in its infancy. There is ongoing work to be done to bring standardization across all the 

rheumatology-related professions. Special emphasis needs to be aimed at pediatric rheumatology 

MLP and eventually also MLP in primary care who may co-manage pediatric rheumatology patients. 

Brief Statement of Strategies and Tactics: The modules for training and certification courses will facilitate 

sub-specialty training both for MLP and physician level providers in adult and pediatric rheumatology 

academic centers. These actions on whole will allow the MLP to manage stable patients with increased 

availability and income stream while at the same time free up critical time for the academic work of 

rheumatology divisions. The College should continue to fund the development, testing and marketing of 

November 2012 63


these courses. A goal of these efforts, beyond enhancement of training and qualifications, should be that 

academic rheumatologists can focus more on physician training, thus ensuring complete understanding 

and competency by the fellows of the entire curriculum. The Foundation should also consider providing 

scholarships for these programs. 

Resources: Financial, volunteer and staff support will be needed for the development of the teaching 

materials in collaboration with members and trainings programs. It is expected that curriculum and 

program development will be a combined undertaking of the ARHP, COE and COTW. 

3.7.2.5. Develop best practices for effective integration of non-physician health professionals 

into academic divisions and practices 

 

 

 

 

 

Specific: This goal specifically targets ARHP membership (past, present and future) within academic 

centers. 

Measurable: Outcomes of this recommendation are measurable, based on retaining talented health 

professionals within academic centers, and should be tracked across time utilizing measurable 

outcomes such as: 

o Increases in specific ARHP membership segments (e.g., NP, PA, APN and research members) 

o Number of academic positions held by these members and maintained over time 

o Increased capacity across academic divisions upon successful integration 

Attainable: Given the work of the College in this area, and with the increased focus proposed, this goal 

is attainable and necessary. 

Relevant: Increased demand for care must result in increased supply, and this segment of the 

workforce must be further developed to assist in meeting this need. 

Timely: The timeliness is clear and has been demonstrated throughout this section. 

Brief Statement of Strategies and Tactics: The panel recommends that the College invest in the 

development of an online guide book to rheumatology that contains a summary of important resources 

and strategies in cooperation with CORC, COTW, COR and utilize existing models (e.g., University of 

Massachusetts, Hospital for Special Surgery) to create a comprehensive guide for academic rheumatology 

divisions across the country. 

Resources: It is expected that substantial financial, volunteer and staff support for the development and 

dissemination of the online guidebook will be needed. 

November 2012 64


3.8. Career development and faculty retention at both early and mid-level points, including national 

mentoring programs and potential new bridging awards at key transition points 


• The development of a successful academic career in rheumatology requires an extended period of 

support, both in terms of appropriate mentoring/training as well as financial support. 

• Key steps in this career development process include attracting top trainees to adult and pediatric 

rheumatology fellowship training programs, provision of strong clinical and research training during 

the fellowship period, successful application for career development awards, and adequate mentoring 

and support for the transition to independence, either as a rheumatology investigator or clinician 

educator. 

• Important progress has been made in recent years, particularly due to efforts and commitment of the 

Rheumatology Research Foundation, to make resources available to support key steps in this career 

development pathway. These include the Rheumatology Scientist Development and Rheumatology 

Investigator Awards, as well as more recently introduced Bridge Funding Award 57 . Other sources of 

support for rheumatology training and career development include the National Institutes of Health 58 

(e.g., F32, institutional T32 and K awards), the Arthritis Foundation 59 postdoctoral fellowship and other 

awards, and the Arthritis National Research Foundation 60 . 

• However, substantial gaps in salary and other support provided by these training and career 

development awards, in conjunction with difficulties fully supporting clinical effort/activities has 

created tremendous financial stresses for academic programs that have secured these awards for their 

trainees due to difficulties in maintaining competitive salaries for awardees 61 . 

• Further, reductions in funds available through the NIH, which has traditionally provided the majority of 

support for physician investigators, has made these funds more difficult to obtain and impeded the 

ability of junior investigators to transition to independence. The Bridge Funding Award has been 

helpful in supporting the transition to K awards 13 , but similar programs to support the transition to R 

awards are not currently available. 

• Junior faculty members striving to develop independent careers as clinician educators face similar 

obstacles due to the limited number of appropriate training and mentored awards in conjunction with 

the aforementioned challenges of generating adequate salary support through clinical work and 

activities, particularly in an academic environment 62 . 

• Rheumatology investigators, who have achieved benchmarks of success as independent investigators, 

such as through receipt of R01 or other comparable awards, face tremendous challenges in 

maintaining adequate support for their salaries and research programs. This situation is due largely to 

the increased difficulty over the past several years in obtaining NIH and other funding in conjunction 

November 2012 65


with other sources of support, such as that generated through clinical work or institutional resources 62 . 

Certain institutions are experiencing additional financial stresses due to regional economic challenges, 

such as the University of California hospitals where state funding has decreased substantially in recent 

years. 

• These challenges have increased in recent years because of several environmental factors, including 

economic forces that have led to decreased support for the research enterprise and the expectation 

that academic faculty attempt to fully support their salary, which has particularly negative impacts on 

rheumatologists and other non-procedural specialties with relatively limited clinical revenues 63 . 

• Thus, retention of faculty, even those who have achieved benchmarks of success, is becoming 

increasingly difficult as the challenges of generating sufficient salary and other requisite support 

increases. Salary gaps are also increasing between academic rheumatologists and those in industry 64 . 

Adding to this growing problem was the recent decision by the NIH to decrease the salary cap by 

$20,000 65 , which further contributes to the financial strain of faculty members with limited sources of 

discretionary or other support. 

• However, faculty retention across departments is statistically associated with a positive perception of 

workplace culture and the perception that work is appreciated 66 . Furthermore, institutions that have 

implemented faculty retention programs have demonstrated a positive effect 67 . 

• These forces and trends raise a critically important issue for academic rheumatology programs, which 

is how best to determine the optimal size of the research enterprise, structure the academic positions 

(both research and clinical) to ensure financial stability and sustainability, and leverage other resources 

available at the institutional, federal, and non-federal levels. 

3.8.2. Recommendations: Career Development 

3.8.2.1. Restructure and expand the Rheumatology Research Foundation’s funding portfolio. 

The proposed expansion would a) more adequately support career development awardees, b) increase the 

flexibility of career development awards, c) facilitate the transition to R (as well as K) awards, and d) provide 

more support to independent (established) rheumatology investigators and clinician scholars. 

• Specific: Proposed targets include the award sizes of current Foundation career development awards, 

award guidelines about receipt of other awards or sources of support concurrently, development of a 

new award(s) to facilitate the transition from K (or comparable) award to R awards, and increases in 

the size (award amount) or number of awards for established investigators. 

• Measurable: Metrics could include the total funding dollars awarded annually to specific award 

categories (e.g., early career, bridge to K, bridge to R, established investigators, etc.) and percent 

November 2012 66


increases per year; the number (total and % annually) of successful K and R awards among applicants; 

the annual number and % of T32 awardees who apply for and receive career development awards (for 

research or clinical scholarship); retention rates for academic rheumatology faculty (or rates of 

departure of rheumatology faculty from academic to other types of positions) 

• Attainable: The tremendous success of the Foundation in increasing its portfolio for research and 

clinical scholarship in rheumatology, including the recent Career Development Bridge Award program, 

supports the feasibility of this goal. In addition, the Foundation has demonstrated the ability to 

collaborate with NIAMS, NIAID, and other institutes, as well as the AF to collect and analyze data 

regarding career development of rheumatology applicants and awardees 13 . The Foundation routinely 

evaluates its programs through portfolio reviews and Blue Ribbon Panel efforts. It would be ideal to 

have crossover between the Foundation’s Scientific Advisory Council and members of this Blue Ribbon 

Panel in these evaluation efforts (the COR chairs sits on the SAC and is already involved in these 

efforts). 

• Relevant: This goal is highly relevant to academic rheumatology based on priorities identified at the 

2012 Rheumatology Training and Career Development Roundtable Discussion, the initial work of the 

Blue Ribbon Panel to identify current challenges and priorities, and feedback from the membership 

about the most pressing problems facing academic rheumatologists today. 

• Timely: The current economic climate, in conjunction with recent trends in the NIH payline, increased 

difficulty in funding academic rheumatology positions and programs, and increasing gaps between 

academic and non-academic rheumatologists underscore the timeliness of this goal. Because none of 

the aforementioned trends and challenges is likely to change substantially in the near future, an 

aggressive timeline for this goal is crucially important. In order to have a significant impact, a goal of 

increasing the total portfolio for support of rheumatology research and clinical scholarship by 10-20% 

per year over the next 5 years is recommended. 

Brief Statement of Strategies and Tactics: In order to achieve this objective, the Foundation would 

develop a first round of revisions and additions to the current awards, outlining the rationale for these 

changes to facilitate fundraising around this goal. This expansion and restructuring will require increased 

fundraising efforts, which in turn, will require new resources (see below). Subsequent changes and 

additions to the portfolio would be introduced based on the amount of additional funds raised through the 

Foundation or identified from other entities. The impact of these changes will be assessed through 

ongoing feedback (via metrics and other information). 

Resources: Increased staff and volunteer time will be needed to accomplish not only the fundraising 

objectives, but also the administration of the grant programs. In addition, current and prior awardees will 

need to be surveyed to determine the impact of any increased funding for career development and 

established investigators in terms of the overall goals of the program. 

November 2012 67


3.8.2.2. Develop a national rheumatology mentoring program. 

Successful mentoring is essential to the success of many activities within academic rheumatology (see 3.2.2.3, 

3.4.2.1-5 and 3.7.2.5). The over-arching program envisioned within this section of the document would have 

the following goals: a) serve as a forum for dissemination of information about available resources and 

opportunities for mentees and their mentors; b) provide ongoing feedback to the Foundation (and other 

external funding agencies) about critical challenges, obstacles to success and potential solutions to ongoing 

challenges that mentees, and their mentors face; c) serve as a forum for identifying new and synergistic 

mentee-mentor pairs (including across institutions and/or geographic regions); and d) provide support and 

recognition to highly committed and successful mentors nationally. This program would also provide an 

opportunity to develop closer links between early-career faculty who are the mentees. 

 

 

 

 

 

Specific: Return on investment for expanded mentoring, best practices for successful mentorship, 

and recognition for excellence in mentorship. 

Measurable: Increase in success rate for achieving independent investigator status with expanded 

mentorship from the College (assumes that baseline success rate can be determined from current 

data); creation of a white paper describing best practices that can be shared with division chiefs 

and program directors; creation of a new set of awards for excellence in mentorship outside the 

faculty member’s institution 

Attainable: The creation of mentoring ‘best practices’ in rheumatology is a realistic goal, but it will 

require volunteer effort from a committed few plus other input. The recognition piece also seems 

realistic once criteria for this award are developed in line with our strategic goals. The development 

of a national mentoring program will require more evaluation, effort, and resources, and is a 

‘stretch goal’ no doubt that will depend on the availability of resources to support it. The AMIGO 

program (ACR/CARRA Mentoring Interest Group) in pediatric rheumatology is a wonderful example 

of a similar effort supported by the College, which has been extremely successful. The launch of the 

College’s online community in 2013 would be a great way kick off efforts in this area. 

Relevance: This goal is highly relevant to academic rheumatology because of the critical need to 

effectively deploy our precious resources to preserve the academic enterprise in a way that will 

sustain the clinical, research, and educational missions of our subspecialty. 

Timely: Fewer fellows are choosing academic careers, especially research careers, because of the 

difficulty in obtaining funding and other financial considerations. Many established investigators in 

rheumatology are also nearing retirement age 68 , which will further strain the academic enterprise 

in the future. The time to act is now because waiting will only require a larger effort later to correct 

the disparity, if in fact, it will be possible to achieve beyond a certain point. 

November 2012 68


Brief Statement of Strategies and Tactics: Strategies include identification of a cohort of mentors for 

leadership at the national level; determining needs through survey of division chiefs and program 

directors; developing a realistic budget aligning with goals and identify funding sources; learning from 

other successful mentorship programs; developing criteria for national mentoring award in rheumatology; 

and maintaining an effective working relationship through the COR. In addition, the College could create a 

“K-club” that would include recipients of NIH K awards and others at a similar stage of mentored career 

development. This entity would have its own list-serve to facilitate scientific and career-building 

networking. Activities could include a luncheon for members of the K-club at the annual scientific meeting, 

to promote face-to-face interactions, and some of the mentors could also participate in this event. 

Resources: Cohort of volunteers with a track record of successful mentoring and willingness to serve the 

subspecialty; staff support through committee on research; budget to support volunteer time. 

3.8.2.3. Identify best practices for structuring academic adult and pediatric rheumatology 

divisions. 

Completion of this objective would allow us to determine how best to enhance factors that will ensure 

high job satisfaction and therefore retention of the most talented faculty. 

• Specific: Understand division structures and practices that facilitate job satisfaction among faculty in 

divisions of Rheumatology. 

• Measurable: A deliverable report that identifies different options for structures and functions for 

clinical practice, education, and research that is linked to job satisfaction and intent to leave analyses. 

This panel strongly suggests the report be published. 

• Attainable: This recommendation will require creation of a task force that will evaluate the factors 

linked to job satisfaction in different professions including academic rheumatology. In order to create a 

survey, it will be necessary to understand organizational structures and practices within rheumatology 

divisions. This is a multi-year project that will require buy-in from division directors. 

• Relevant: In this era of limited ability to increase financial resources, it is essential to understand other 

sources of job satisfaction that enhance retention of academic faculty. 

• Timely: Within a 5-10 year time frame, there is likely to be limited capability to change the fiscal 

realities faced by academic divisions. For this reason, it is imperative to understand what motivates 

academic faculty to stay (or leave) and develop strategies that could be implemented by rheumatology 

divisions to increase job satisfaction. 

Brief Statement of Strategies and Tactics: This recommendation will require a task force or subcommittee of 

the COTW to research the job satisfaction literature in medicine and other professions, and then specifically 

understand the factors that influence job satisfaction in rheumatology divisions. In order to create this survey, 

November 2012 69


it will be essential to understand how rheumatology divisions are organized with respect to clinical, 

educational, and research to probe how structure and function at a divisional level influences job satisfaction 

and likelihood to leave. 

Resources: This will be a fairly resource intensive project that will require a task force of division chiefs, 

program directors, and young faculty. The group should be charged with conducting background research on 

job satisfaction in general and more specifically in academic medicine. Developing a survey to inform 

academic divisions will require understanding the options for divisional organization and practices. The results 

of the survey should be shared with division directors and published. Significant staff time will be required to 

keep volunteers on task, assemble background information, develop the survey, and assist with publication. 

November 2012 70


3.9. Leadership Development within the College, the rheumatology research community, and academic 

rheumatology centers, to ensure that there is a robust supply of future division chiefs, center 

directors, fellowship directors, clinical program chiefs and College leaders. 


Effective leaders are essential to advance rheumatology in the future, including division chiefs, training 

program directors, clinical service chiefs, educational leaders, center directors, heads of research 

programs or consortia, and College leaders. 

• The current leadership cohort in rheumatology includes many individuals in the later stages of their 

careers. For example, the mean age of academic rheumatology division chiefs is 58 69 

• The demographics of this aging leadership does not reflect the current demographics of rheumatology, 

which have changed markedly over the past 20 years, with a greatly increased proportion of women 

and expanding ethnic diversity 53 

• A shortage of leaders already exists in rheumatology, as indicated by some rheumatology divisions now 

being led by non-rheumatologists or entire divisions merged into other subspecialty units – at times 

after failure of prolonged searches to recruit rheumatologist leaders 69 

• A worsening leadership shortage is imminent, that likely reflects shortfalls in recruitment of new 

rheumatology fellows in the 1990s 70 

• The College has been successful in developing new leaders, with its officers reflecting the recent 

increase in the proportion of women in rheumatology, each committee having at least one designated 

slot for an early career member, and has developed useful programs that introduce new committee 

members to the structure and functions of the College; however, the organization lacks a 

comprehensive model or program for training future leaders of the College. In addition, the College is 

overly reliant on the astute judgment, unique organizational memory and unequaled skills of its 

executive vice-president to identify evaluate and groom future leaders. This process should be 

supplemented going forward by a more formal leadership training and evaluation process. 

• While leadership development programs exist for academic medicine 71 which cover issues that span 

across subspecialties, none of them are specifically focused on issues of unique or special interest to 

rheumatology 

• While the COTW has organized a Division Chiefs forum at the annual meeting for several years, other 

specialty groups, such as cardiology, geriatrics and general internal medicine, have gone further in the 

development of functional division director groups that are focused on addressing issues unique to 

their specialized divisions 72 There is precedence for this, as the College will inaugurate a new award 

that recognizes a distinguished training program director this year. 73 

November 2012 71


3.9.2. Recommendations: Leadership Development 

3.9.2.1. Update and analyze the state of leadership in academic divisions of rheumatology on 

an annual basis. 

• Specific: Structured collection of vital information about academic rheumatology leadership 

• Measurable: Assembly of a useful database within 1 year 

• Attainable: The COTW currently engages this group and has experience collecting similar data. 

• Relevant: It is necessary to have data about such an issue in order to assess the scope of the problem 

and implement calibrated actions. 

• Timely: Action now is important because a shortage of new leaders is likely to become more severe in 

the near future. 

Strategies and Tactics: An academic unit should be defined as a rheumatology unit affiliated with a medical 

school and/or fellowship training program. The new data base should encompass the number/proportion of 

divisions led by a rheumatologist, the number of division chief positions filled versus vacant (or occupied by 

acting or interim leaders), the male/female balance and race/ethnicity of division leaders, the mean and 

median ages of division leaders, the number and proportion of current leaders who expect to step down from 

their positions in one, three or five years, and similar data for training program leaders. Data regarding other 

senior academic leadership positions held by rheumatologists should likewise also be captured. Additional 

demographic and professional information may also be of interest, such as the career emphasis of division 

chiefs and training program directors (physician-scientist, clinical researcher, clinician-educator, etc.), and the 

identity and characteristics of other key leaders in academic units. Collection and analysis of this data annually 

will allow the College to accurately track and proactively alleviate impending leadership shortages. This 

information can be assembled into a “dashboard” that will help to track the state of academic rheumatology 

leadership nationally, and that will be a valuable tool to support the expanded scope of a division directors 

group. 

Resources: Staff and Volunteer time in the training area, as well as administration and governance would be 

needed, but is expected to be minor and incremental increased effort at the front end. 

3.9.2.2. Create comprehensive leadership development and mentoring programs. 

 

 

 

Specific: Training of new and current academic rheumatology leaders 

Measurable: Number of leaders trained each years 

Attainable: Similar programs already exist, although not specific for rheumatology. 

November 2012 72


 

 

Relevant: This initiative would give added skills to our academic leaders. 

Timely: A leadership development program could be developed in 12 months. Implementation of 

this program in the near future is appropriate to meet the needs of our academic leaders, 

especially new and younger leaders. 

Strategies and Tactics: These programs could be geared to academic rheumatology; for division directors, 

training program directors, other academic leaders and future College leaders. This could potentially be done 

in partnership with existing national medical academic leadership development programs, with core material 

and training through such entities supplemented by rheumatology-specific and ACR-specific material and 

training modules. One highly-regarded national leadership development program that could be linked into an 

overall ACR plan is the Executive Leadership in Academic Medicine program, which is designed specifically for 

women 74 . Leadership development programs for directors of clinical programs will need to include an 

emphasis on business skills, finance and personnel management. 

Resources: Staff and Volunteer time in the research and training area, as well as administration and 

governance would be needed, especially to liaise effectively with external groups and create partnerships. 

3.9.2.3. Develop a comprehensive and formal evaluation process for vetting and selecting 

volunteer leaders. 

 

 

 

 

 

Specific: This goal is broader than just academic rheumatology and should include all areas of the 

College. Development of an evaluation system to assess and track the skills, leadership potential 

and any gaps in leadership skills of College volunteers. 

Measurable: Implementation of a new tracking and reporting mechanism within the CRM database 

within 12 months that can be used by the Nominations Committee to assess the preparation and 

qualifications of ACR volunteers for leadership positions. This would also go a long way toward 

ensuring volunteer engagement. Currently, many positions are filled with ‘known’ members as 

opposed to those who have been vetted through subcommittees and other activities and shown a 

true interest in being involved. Committee members willing to put in the time and effort needed 

are that much more valuable to the organization. Properly vetting and evaluating these members 

will help them gain recognition at a higher level within the organization. 

Attainable: The College already does some evaluations of committee members – this proposal 

would enhance current efforts and make them more useful for the nominations process. 

Relevant: Strong future leadership will indirectly strengthen academic rheumatology. Skills 

developed during volunteer work for the College can carry over into academic tasks. 

Timely: An enhanced evaluation system can be implemented within 12 months. If this action is of 

value to the College, expeditious implementation is appropriate. 

November 2012 73


Strategies and Tactics: This program would include a clear pipeline in order to vet future leaders appropriately 

and allow them time to learn about the various functions of the college. A program should also be put in place 

for subcommittee and committee members, board members, etc. that is integrated with the nominations 

process. This will support leadership development of volunteers from community practice backgrounds as well 

as from academic units. 

Resources: Substantial staff and Volunteer time in the administration and governance department would be 

needed, and it will be important to liaise with COTW volunteers and staff if including division chiefs, program 

directors, etc. A budget would also need to be developed as this recommendation may involve formalized 

training with skilled facilitators and educators. 

3.9.2.4. Create a rheumatology division directors group 

 

 

 

 

Specific: Development of a Division Chiefs association within the College, with a scope of activities 

analogous to that of the Fellowship Training Program Directors. 

Measurable: Definition of a new structure and role for a division chiefs association; annual 

meetings of this association 

Attainable: Other specialties have developed such an entity. 

Relevant: This association would allow more interactions between Division Chiefs to address 

common problems that confront academic rheumatology. 

Timely: It could take 12 months to develop the structure for this new entity, and another 6-12 

months to organize its first meeting. 

Strategies and Tactics: This would build upon the current division chiefs’ forum at the annual meeting to 

create a more formalized rheumatology division directors organization, drawing from its experience with the 

rheumatology training program directors. 

To begin the process of forming this new group, and drawing on DORTP (Directors of Rheumatology Training 

Programs) beginnings, perhaps a small group of senior rheumatology division directors could be appointed to 

draft a set of preliminary bylaws for a proposed rheumatology division directors group. With this draft as a 

starting point, the larger group of division directors could then meet and finalize the bylaws for approval by 

the ACR Board. 

Resources: Substantial staff and volunteer time in the training department would be needed, and it will be 

important to liaise with academic centers. A budget would also need to be developed as this recommendation 

will likely involve meetings and conferences, targeted communications, online resources, etc. 

November 2012 74


3.9.2.5. Consider recognition programs for academic leadership 

Having initiated a training program director award in 2012, the College should now consider appropriate 

additional mechanisms to recognize outstanding leadership in academic rheumatology. 

 

 

 

 

Specific: Creation of an additional award of distinction 

Measurable: Establishment of the award, submission of multiple competitive applications for the 

award 

Attainable: The College offers several awards already, and has lots of experience in selection of 

awardees. 

Relevant: This award would encourage and recognize excellence in academic leadership. 

Timely: This award could be in place by 2014. 

Strategies and Tactics: These recommendations should be implemented by the Nominations Committee, 

which should be renamed the Committee on Nominations and Leadership Development, and given a yearround 

roster of duties compared to its current single flurry of activity in the summer. This new committee 

would have the responsibility for developing leadership training programs, in consultation with professional 

experts in this field. The committee would analyze the annual rheumatology leadership report 

(recommendation 1) and provide reports and appropriate recommendations to the ACR Board. 

This committee would work closely with the new rheumatology division directors group, which would provide 

input regarding leadership development strategies and programs, organization of mentoring activities, gaps in 

division chief skills that could be addressed by targeted training, and implications of updated analyses of the 

rheumatology leadership “dashboard.” 

Resources: Staff and Volunteer time in the administration and governance department would be needed, and 

it will be important to liaise with other groups within the college. Effort would be minimal, and again mostly 

involve set-up and initiation. 

November 2012 75


3.10. Formally demonstrating value (financial, scientific, clinical and educational) of academic 

rheumatology, envisioning departments of internal medicine and pediatrics, and medical 

schools as new targets for ACR interactions; Increasing public awareness of contributions of 

academic rheumatology to development of new scientific knowledge, new therapeutics, and 

new approaches to clinical care and education 


 

 

 

 

It is imperative to formally demonstrate the value of clinical and academic rheumatology, including the 

financial, scientific, clinical, and educational contributions that rheumatologists and rheumatology 

health professionals in academic medical centers make. Demonstrating the value of academic 

rheumatology is also is directed externally towards the public, healthcare providers in other specialties, 

key influencers in the insurance industry, health policy stakeholders, granting agencies, other federal 

agencies and organs including the Veterans Administration, Centers for Disease Control, Centers for 

Medicare and Medicaid Services, and members of Congress who develop and implement policies for 

training, practice reimbursement and research. 

It has been estimated that academic rheumatologists generate more than $10.00 for every $1.00 they 

receive for an office visit 75 . This figure provides strong evidence of the value of the financial 

contributions of rheumatology divisions in academic centers, even if the division is considered a “cost 

center.” The impact of revenue from care of patients with subspecialty diseases such as rheumatoid 

arthritis is particularly striking. Every professional fee dollar charged by a rheumatologist for an RA visit 

generates approximately 20-30 fold additional charges for the enterprise 75 . 

The rapid pace of change in the healthcare landscape, including reimbursement as well as knowledge 

and technology advances, requires that effective health care systems be designed in academic 

rheumatology centers to guarantee dependable and coordinated chronic disease care as mandated by 

the Institute of Medicine Committee 76 . Rheumatologists are well suited to meet this challenge, as they 

are experts in the delivery of highly specialized and optimal patient care, which is of better quality, 

often less costly and offering better value for the health care dollar expenditure. 

The importance of providing high value, quality care in arthritis is highlighted by recent statistics from 

the National Center for Chronic Disease Prevention and Health Promotion 77 which demonstrate that 

arthritis and rheumatic diseases are not only the main cause of disability in the United States but cost 

more than 85 billion dollars annually and affect more than 43 million adults in the United States, 

figures that will continue to grow 78 . These figures highlight the need for ensuring access to 

rheumatologic care, including assurance of a trained workforce. In addressing these needs, academic 

rheumatology centers are well positioned to provide optimal data-driven care, but the system for 

providing this care will require redesign 79 . 

November 2012 76


 

The ability of academic rheumatology to meet the clinical practice and manpower demands into the 

future is highly dependent upon having an academic environment that provides resources for and 

promotes excellence in clinical teaching and clinical research to both attract and retain talented 

physicians and other healthcare providers to this field 62,80 . Workforce data indicate that access demand 

for rheumatologists continues to grow. According to survey of the American College of Rheumatology, 

rheumatologist demand is estimated to be around 6,500 by 2020, with a supply of about 4,800, 

yielding a shortfall of about 1,700 rheumatologists 5 . Approximately 30% of those leaving academic 

practices go into private practice, and about 75% of academic medical centers are recruiting. This 

represents a substantial challenge for the success of academic rheumatology units and the need for 

training and integration of mid-level providers. 

3.10.2. Recommendations: Demonstrating Value 

3.10.2.1. Develop a dashboard with tools and metrics to facilitate best practices in academic 

centers 

The panel recommends that the ACR should develop a dashboard of recommendations, tools and metrics 

which can be used by academic medical centers to foster their implementation and sharing in academic 

practice 

• Specific: 

o Standard disease outcome measures 

o Management recommendations for treatment, disease and drug monitoring, lifestyle 

o Rheumatic disease diagnosis and classification 

o Practice tools: EMR resources, appointment management tools, coding assistance 

o Financial metrics for salary, clinical practice, fellowship support, institutional cost sharing 

o Clinical trials information and enrollment site 

• Measurable: Access and downloads from the ACR Academic medical center dashboard website 

• Attainable: 

o Availability of practice management tools. 

o RA registry is available and is demonstration of feasibility 

o Disease diagnosis, assessment, and treatment instruments and recommendations are available 

o Coding assistance available through ACR 

• Relevance: Relevant to recommendation 3.8.2.3 and 3.10.2.2, this recommendation addresses the 

need to enhance the efficiency and productivity of practices 

• Timeliness: Availability of many of the resources 

November 2012 77


3.10.2.2. Implementation of data sharing resources to share disease assessment and outcome 

measures 

The panel recommends the implementation, in concert with proposals in sections 3.3 and 3.5, of current 

measures, and development of further disease assessment and outcome measures. With the implementation 

of these measures in clinical practice, the academic units should also increase their capability for sharing 

clinical data infrastructure among academic communities. 

• Specific: 

o Use of standard disease assessment and reporting forms intra - and inter-institutionally. 

o Development, implementation, and testing of standard treatment approaches to rheumatic 

diseases. 

• Measurable: 

o Quantified patient outcome assessment based on practice guidelines. Rheumatology-geared 

Healthcare Effectiveness Data and Information Set metrics have been developed for 

rheumatoid arthritis, osteoporosis, and low-back pain. Academic rheumatology can use, and 

further develop, outcomes metrics applicable to the HEDIS goals. 

o Comparative effectiveness research metrics application to treatment strategies effects, for 

example patient and society financial impact, functional disability, absenteeism and quality of 

life indices 


o Many academic centers are already collecting standardized disease outcome metrics. Other 

management tools such as EMR are available which will enable to sharing of information, and 

facilitate systematic assessment of disease management protocols 

o Electronic medical record (EMR) use is prevalent in academic rheumatology centers (>70%). The 

ACR Benchmark survey 4 indicates that the EMR is used for test ordering. The EMR is integrated 

with registries in approximately 30% of cases. It is used to update medication lists in nearly 90% 

of practices overall, and is used for staff communications and patient communications. 

o RHIT can foster the aims of this recommendation 

• Relevance: 

o Addresses the need to enhance the efficiency and productivity of practices, which will aid in 

demonstrating the value and quality of rheumatologic care to the patients, the institution and 

payers in the realms of clinical practice, training, research and financial impact. 

• Timeliness: 

o National quality mandates and financial pressures on academic rheumatology centers 

o Many of the resources are already available 

November 2012 78


3.10.2.3. Enhance, promote, and demonstrate value of improved practice models in academic 

rheumatology 

• Specific: 

o Rheumatology advocacy: Increased public and key influencer awareness of contributions of 

academic rheumatology to patient health, outcomes, care quality, and development of new 

scientific knowledge and new therapeutics 

o Promote including maintaining and starting, hospital-based clinical fellowship salary support. 

o Subspecialization: Promotion of shared clinics for management of chronic rheumatic diseases 

and management and prevention of disease-related comorbidities. 

o Promotion of subspecialty training and practice clinics in areas such as scleroderma, lupus, 

rheumatoid arthritis, vasculitis and myositis. These clinics can be tied to other specialists for 

management of comorbid states. 

o Demonstrating positive financial and educational impact of maintaining (or starting) hospitalbased 

clinical fellowship salary support 

o Expansion of cross-disciplinary integration with combined practice clinics 

o Training, utilization and integration of mid-level providers to serve in the health care team 

who follow standard disease management strategies. 

• Measurable: 

o Demonstration of outcomes and practice efficiencies, with recording of metrics reflecting 

improved patient access to rheumatologic care, numbers of new-to-clinic patients 

o Academic rheumatology unit net operating income 

o Downstream impact of rheumatology activities and referrals in the institution. 

o Demonstration of financial impact performance of MLP in the practice. 

o Financial impact of increased unique patient referrals 

o Financial, as well as training opportunity and public relations impact of clinical trials 

placement strategies. 

o Measurement of cost reduction in inefficiencies among subgroups of patients often 

preferably seen in academic medical centers such as Medicare, Medicaid, and the 

uninsured. 

o Measurement of total healthcare costs in patients with rheumatic disease managed in 

multidisciplinary setting, including bundled payment (full spectrum cost for example: a 

rheumatoid arthritis patient for direct disease-related costs but also expenditures for 

cardiovascular and pulmonary disease or in lupus for rheumatologic, pulmonary, 

cardiovascular, and renal disease management, and prevention). 

o Reporting of waiting times to be seen for new and follow-up evaluations in academic 

medical centers. 

o Demonstration of positive financial and educational impact of maintaining (or starting) 

hospital-based clinical fellowship salary support 

November 2012 79


o Tracking of impact and success of PR campaign and lobbying efforts with respect to 

reimbursement and funding for rheumatology patient care, education and research. 


o Data exist regarding rheumatologists’ work hours and compensation 

o Measurable financial impact data of the contribution of academic rheumatology to their 

centers are available or obtainable. 

o In the academic setting, there are a few centers which have systematically evaluated the 

impact of the addition of mid-level providers or practice reorganization which can provide 

benchmark metric 

o ACR has developed a midlevel provider training course, which has been very successful 

o Electronic medical record (EMR) is available in most academic rheumatology practices 

o Useful data are available or obtainable regarding practice patient visit codes and Medicare 

assignments 

• Relevant: 

o Academic rheumatology centers are well positioned to demonstrate their value in achieving 

the goals of efficient and effective disease management, advancing the science of 

rheumatology, providing state of the art training, and advancing public awareness of 

rheumatic diseases. Relevant to the mission and success of academic rheumatology units 

are: 

• Development and use of technologies, therapeutics, and diagnostics 

• Expense management and patient access 

• Management of payer mix. The numbers of the under- and uninsured patients 

requiring rheumatologic care and demands by payers for lower costs adversely 

impact academic centers, which typically have large overhead and lack the flexibility 

to change rapidly in response to the dynamic medical business environment. 

• Workforce retention and development. High attrition rate of academic medical staff 

to private practice and industry efficiencies. Need for midlevel workforce to help in 

managing routine patient visits 

• Improvements in clinical research efficiencies. 

• Timeliness: 

o Academic medical centers are under increasing financial pressure from unfavorable patient 

mix, payer schemes, and salary reimbursement, and practice inefficiencies, direct costs of 

medications and technologies that are major challenges to the academic medical center’s 

ability to pursue its fundamental purpose of advancing patient care, educational 

rheumatologic disease, and research. 

o The current financial climate in the US, with decreasing funding for research and education 

and uncertainties related to the healthcare environment with respect to national and local 

November 2012 80


healthcare reform initiatives are strong arguments for the timeliness of these 

recommendations which should be addressed in the next 2-5 years 

3.10.2.4. Development and adoption of new technologies in diagnostics and therapeutics 

• Specific: 

o Implementation of technologies including musculoskeletal ultrasound for practice 

management, research, and training. 

o Development of biomarkers useful in predicting disease activity, severity damage, prognosis, 

and therapeutic response. 

o Foster formal clinical research training and promotion of clinical trials and clinical trial 

placements in academic medical centers. 

o Novel therapeutics shared through academic medical center trials networks 

o New models of academia/industry partnership 

Measurable: Demonstration of financial impact and disease outcome impact of novel technologies 

(based on standard rheumatologic disease-specific outcome measures). The number and success 

of trials can also be tracked. 


o Musculoskeletal ultrasound (MSUS) is being considered, or used in multiple rheumatology units 

already 

o Training in MSUS is available; certification is being developed 

o Examples of successful networks such as the VCRC demonstrate that the goal of trial network 

enhancement is attainable 

• Relevance: 

o Academic medical centers must be in a position of leadership with respect to development and 

implementation of novel technologies to advance their mission of education and research in 

rheumatic diseases. Increasing financial pressures as well as national policy initiatives such as 

CTSA collaborations underscore the importance of addressing the goals of this 

recommendation 

o Suboptimal clinical trial participation in recent years. Low interest in clinical trials resultant from 

institutional burdens in clinical research and recruitment challenges lead to high indirect costs 

and uncoordinated patient recruitment. These are among factors which disadvantage academic 

medical centers compared to private groups which are much more efficient and cost effective, 

adversely affecting the academic medical center ability to participate and exhibit leadership in 

development and assessment of novel therapeutics. 

 

Timeliness: The rapid growth and development of technologies, uncertainty about their utility and 

usefulness, and data infrastructure as well as the current fiscal environment highlight the 

timeliness of this recommendation 

November 2012 81



strategies the vision and tools to attain these goals. These could include: 

 

 

 

 

 

 

 

 

 

 

Development of a dashboard of resources 

Continued development and expansion of registries (for example, the Rheumatology Clinical 

Registry) not only for collection of data to document current quality measures but also for 

implementation and assessment of disease management programs and domains such as drug 

safety. The ability of this registry to serve as a tool for benchmarking practice performance and 

completing quality improvement modules for maintenance of certification is a small step in the 

right direction but should be markedly expanded. 

Promote the rheumatology informatics systems for effectiveness (RISE) as a tool to enable secure 

access to data collected through electronic health record systems. This can be used to provide a 

mechanism for practice improvement meeting external quality reporting requirements as well as 

advancing clinical practice research. 

Develop a strategy manual of “key financial indicators for academic rheumatology centers and how 

to achieve them” 

Training in obtaining comparative effectiveness research funding from the patient-centered 

outcome research initiative and other organizations. 

Leverage current public relations efforts to publicize and promote the benefit and importance of 

benefits of rheumatologic care developed and practiced by academic centers, and to leverage and 

promote funding for academic rheumatology interests at the federal, state and local level and in 

the private sector. 

Expansion of mid-level provider training through College programs 

Catalogue and coordinate comparative effectiveness research projects among academic medical 

centers. 

Catalogue and coordinate funding for clinical trials across academic medical centers. 

Continue and enhance the “Academic Rheumatology Chiefs” forum at the Annual Meeting, in the 

context of a new ACR association of rheumatology division directors. 

Resources: It is expected that this would involve significant time and effort from staff and volunteers in the 

areas of RHIT, QOC (QM), MARCOMM, GAC, in collaboration with CORC (would assist in developing strategies 

for assessing cost and outcomes of rheumatologic care and the impact of various compensation plans). 

November 2012 82


4. Summary of Recommendations 

Issue Reference Recommendation Proposed 

Assignment 

3.1. Funding 3.1.2.1 Develop a method and schedule to acquire and analyze in COR 

real time sufficient levels of serial data to provide informed 

recommendations regarding strategies to improve funding 

within academic rheumatology. 

3.1. Funding 3.1.2.2 Improve the review of rheumatic disease research within 

the NIH Center for Scientific Review through the 

development of a new study section with a preponderance 

of members with expertise in rheumatic disease clinical 

research. 

COR, EC 

3.1. Funding 3.1.2.3 Establish additional formal and informal interactions with a 

targeted group of professional and lay research-intensive 

organizations to identify common policy and funding goals 

that can be pursued in a collaborative manner. 

3.1. Funding 3.1.2.4 Increase formal intra-organization interactions to assure 

that there are timely and focused research-related 

legislative recommendations pursued by the ACR. 

3.1. Funding 3.1.2.5 Continue very successful efforts by the Foundation to 

expand funding that supports the academic rheumatology 

research enterprise and the research training pipeline. 

Strong consideration should be given to expanding bridge 

funding to additional transition points within academic 

research careers. 

3.1. Funding 3.1.2.6 Aggressively advance the rheumatology research agenda 

with a focus on utilizing this document to increase 

awareness and funding for the major rheumatic diseases. 

3.1. Funding 3.1.2.7 Develop strategic funding approaches to the multitude of 

low prevalence rheumatic diseases, found especially in 

children. 

3.2. Scope 3.2.2.1 Develop a program and schedule for defining and tracking 

the scope of the specialty of rheumatology, to stay ahead of 

the curve with respect to the ever-changing landscape of 

the practice of medicine in the US. 

3.2. Scope 3.2.2.2 Develop advanced fellowship training or ‘sub-specialization’ 

programs. 


Research 

Foundation, COR 

GAC, PAC, COR 


Research 

Foundation 

COR, GAC 

COR, SAC 

CORC, COR, 

COTW in 

collaboration 

with ARHP, CJP, 

COE 

COTW 

November 2012 83


3.2. Scope 3.2.2.3 Develop collaborative interdisciplinary clinical care models. CORC, in 

collaboration 

with COTW, 

COE, CJP 

3.2. Scope 3.2.2.4 Develop meaningful partnerships to create disease 

management guidelines for conditions whose care requires 

coordinated efforts between rheumatologists and other 

specialists. 

QOC 

3.3. Research 

Consortia 

3.3. Research 

Consortia 

3.3. Research 

Consortia 

3.3. Research 

Consortia 

3.4. New 

Technologies 

3.4. New 

Technologies 

3.3.2.1 Address potential underutilization of existing registries and 

biorepositories. 

3.3.2.2 Maintain valuable collections and sources of patient data 

and biological samples. 

3.3.2.3 Leverage existing funding sources by partnering with the 

CTSAs and with Industry 

3.3.2.4 Organize a working group of the COR to discuss potential 

new research resources that would have high value for the 

rheumatology scientific community. 

3.4.2.1 Support the development and implementation of tools for 

incorporation of patient-derived data into academic 

medical practices and research. 

3.4.2.2 Support the development of clinical management tools and 

systems to improve efficiency and outcomes of care, 

address the limitations and challenges of the current 

healthcare system, and demonstrate the value of academic 

rheumatology programs. 

RHIT, in 

collaboration 

with COR, 


Research 

Foundation 

RHIT, 


Research 

Foundation, 

COR, with 

collaboration 

from GAC 

COR, 


Research 

Foundation 

COR 

COR, 


Research 

Foundation, 

RHIT 

CORC, COR, 


Research 

Foundation 

November 2012 84


3.4. New 

Technologies 

3.4. New 

Technologies 

3.5. Clinical 

Data 

Infrastructure 

3.6. 

Regulatory 

Burdens 

3.6. 

Regulatory 

Burdens 

3.6. 

Regulatory 

Burdens 

3.6. 

Regulatory 

Burdens 

3.4.2.3 Consider and define the appropriate application of imaging 

technology in academic rheumatology practices and 

training programs, and support the active contribution of 

academic rheumatology programs to development of new 

imaging technology to improve patient care. 

3.4.2.4 Encourage and support research aimed at development of 

predictive tools, including clinical, demographic, patientderived 

and biologic parameters, to improve patient 

management. 

3.5.2.1 Continue significant investment in Registries and Health 

Information Technologies 

3.6.2.1 Collaborate with other organizations to understand and 

support current activities that would lower research 

regulations at academic centers. 

3.6.2.2 Ensure organizational accountability with respect to 

following best practices in administration of programs 

3.6.2.3 Develop a comprehensive strategy to address new ACGME 

reporting requirements. 

3.6.2.4 Ensure that academic rheumatologists may efficiently 

complete maintenance of certification programs. 

CORC, MCOC, 

with 

collaboration 

from COTW, 

COR, 


Research 

Foundation 

COR, 


Research 

Foundation 

ACR Board, 

RHIT, QOC, 

CORC 

COR, with 

collaboration 

from GAC, 


Research 

Foundation 

College-wide 

effort, led by 

Administration 

and 

Governance, 

engaging all 

standing 

committees 

COTW (in 

progress) 

COE 

November 2012 85


3.6. 

Regulatory 

Burdens 

3.7. Workforce 

Development 

3.6.2.5 Assure consideration for the inclusion of academic clinical 

practices in Registry and Practice work plans to assist with 

implementation of reporting requirements. 

3.7.2.1 Collect annual data to assist with decision making 

concerning the needs of training and workforce 

development. 

RHIT, CORC 

COTW 


Development 


Development 


Development 

3.7.2.2 Increase funding for adult and pediatric rheumatology 

workforce development. 

3.7.2.3 

Increase efforts aimed at increasing the rheumatology 

workforce and limiting workforce attrition. 

3.7.2.4 Increase the support of adult and pediatric rheumatology 

units in providing specialized training for physicians and 

mid-level providers. 


Research 

Foundation, 

COTW, ARHP 

COTW, 


Research 

Foundation 

COTW, ARHP, 


Research 

Foundation 


Development 

3.8. Career 

Development 

3.8. Career 

Development 

3.8. Career 

Development 

3.9. 

Leadership 

Development 

3.7.2.5 Develop best practices for effective integration of nonphysician 

health professionals into academic divisions and 

practices. 

3.8.2.1 Restructure and expand the Rheumatology Research 

Foundation’s funding portfolio. 

ARHP, CORC, 

COTW, COR 


Research 

Foundation 

3.8.2.2 Develop a national rheumatology mentoring program. COR, Division 

directors group 

3.8.2.3 Identify best practices for structuring academic adult and 

pediatric rheumatology divisions. 

3.9.2.1 Update and analyze the state of leadership in academic 

divisions of rheumatology on an annual basis. 

Division 


Division 


November 2012 86


3.9. 

Leadership 

Development 

3.9. 

Leadership 

Development 

3.9. 

Leadership 

Development 

3.9. 

Leadership 

Development 

3.10. 

Demonstrating 

Value 

3.10. 

Demonstrating 

Value 

3.10. 

Demonstrating 

Value 

3.10. 

Demonstrating 

Value 

3.9.2.2 Create comprehensive leadership development and 

mentoring programs. 

3.9.2.3 Develop a comprehensive and formal evaluation process for 

vetting and selecting volunteer leaders. 

Nominations 

and Leadership 

Development 

Committee 

Nominations 


Development 

Committee 

3.9.2.4 Create a rheumatology division directors group. Nominations 


Development 

Committee, with 

collaboration 

from COTW 

3.9.2.5 Consider recognition programs for academic leadership. Nominations 


Development 

Committee 

3.10.2.1 Develop a dashboard with tools and metrics to facilitate 

best practices in academic centers. 

3.10.2.2 Implementation of data sharing resources to share disease 

assessment and outcome measures. 

3.10.2.3 Enhance, promote, and demonstrate value of improved 

practice models in academic rheumatology. 

3.10.2.4 Development and adoption of new technologies in 

diagnostics and therapeutics. 

CORC, in 

collaboration 

with RHIT, QOC 

and other 

committees 

CORC, QOC 

CORC 

RHIT ,with 

collaboration 

from QOC, CMC, 

GAC, CORC 

6. Next Steps Annual progress reports Executive 

Committee 

6. Next Steps Convene next panel by fall 2017 Executive 

Committee 

November 2012 87


5. Additional Areas to Consider 

In addition to the critical issues and recommendations outlined in section 3, the panel has identified 

additional areas for future consideration by the Board and committees of the College as they enter into 

strategic planning and develop project proposals over the next few years. These areas include: 

 

 

 

Increased international collaborations and development of research in rapidly developing countries 

in Asia and Latin America 

Enhancement of participation of under-represented minority professionals in academic 

rheumatology 

Evolution of the relationships between academic units and the pharma/biotech sector 

November 2012 88


6. Next Steps 

It is expected that this final report will be utilized by the College and Foundation in their upcoming strategic 

planning exercises, and that many projects will result from the recommendations contained herein. In order to 

ensure that each of the recommendations outlined in Section 3 are considered by the appropriate 

departments, committees and councils within the College, the panel has developed a set of next steps to 

facilitate further discussion and action over the next several years. 

Dissemination Plan 

A summarized version of this report will be made publicly available on the ACR website, and will also be 

distributed to key stakeholders at the NIH and other funding agencies, as well as to division chiefs and internal 

medicine program directors, other specialty societies, etc. A white paper may also be submitted to Arthritis & 

Rheumatism on behalf of the panel to share the outcomes with the membership (pending approval by the 

Executive Committee). 

Once the final report has been accepted by the Executive Committee of the ACR, the report will be shared 

with committees and councils, who will be charged with evaluating the recommendations and creating 

appropriate action plans and projects accordingly. This will be extremely helpful in assisting the College as it 

plans for the future, as well as to increase organizational capacity to achieve the goals outlined in this report. 

Projects, Programs and Capacity 

Pending acceptance of this final report, members of the panel will be available to liaise with other committees 

within ACR to discuss specific projects discussed above and provide guidance with respect to the intention of 

the goals and strategies. It is expected that some of these projects may be developed in time for the May 2013 

project cycle. 

Several recommendations contain resources that are not yet available (e.g., staffing, infrastructure, 

technologies, etc.) and will require a direct investment from the College to build organizational capacity. It is 

the hope of the panel that the departments referenced in these recommendations will move quickly in order 

to accomplish these important goals. 

November 2012 89


Monitoring Progress 

In order to monitor and evaluate the plan laid out in this report, the panel respectfully requests annual 

progress reports from the ACR Executive Committee to the Board of Directors. These reports can be quite 

simple, including a brief statement of the outcome of each of the suggested actions laid out in section III of 

this report in table format, with the understanding that many of these goals are longer term and the status for 

some years will remain ‘pending.’ 

Dr. Holers, as an ACR board member, has volunteered to assist in the compilation of these reports, which will 

require cooperation from nearly all ACR departments, committees and councils. This reporting process would 

allow for continual evaluation of the efficacy of the recommended programs and services outlined in the 

report. 

It is the recommendation of this panel, that a new panel be convened no later than the fall of 2017 to evaluate 

the health of academic rheumatology within the US, utilizing the 2012 report and new data sources available 

as a result of the work of the College between 2012 and 2017 to increase capacity in the areas recommended. 

November 2012 90


7. Acknowledgments 

Blue Ribbon Panel Members 

Co-Chairs: 

David A. Fox, MD 

University of Michigan 

Staff Liaison: Mary Wheatley 

Sr. Director, Research and Training 

American College of Rheumatology 

V. Michael Holers, MD 

University of Colorado Denver 

Representational Members: 

ACR Executive Committee 

E. William St.Clair, MD 

Duke University 

Association for Rheumatology Health 

Professionals 

Daniel E. Schaffer, PA-C 

Mayo Clinic 

At-Large Members: 

Gary Bryant , MD 

University of Minnesota 

Lindsey A. Criswell, MD, MPH 

University of California, San Francisco 

Leslie J. Crofford, MD 

University of Kentucky 

Mary K. Crow, MD 

Hospital for Special Surgery 

ACR Committee on Research 

Bruce N. Cronstein, MD 

New York University 

ACR Committee on Training and 

Workforce Issues 

Abby G. Abelson, MD 

The Cleveland Clinic 

Ellen Gravallese, MD 

University of Massachusetts Medical School 

Elizabeth W. Karlson, MD 

Brigham and Women's Hospital 

William J. Koopman, MD 

University of Alabama at Birmingham 

ACR 2020 Panel 

ACR Registry and Health Information 

Technology Committee 

William F. Harvey, MD 

Tufts Medical Center 

Eric L. Matteson, MD 

Mayo Clinic 

William Robinson, MD, PhD 

Stanford University 

ACR Pediatrics Special Committee 

Hermine I. Brunner, MD, MBA, MSc 

Cincinnati Children's Hospital Medical 

Center 

Maria E. Suarez-Almazor, MD 

University of Texas MD Anderson Cancer 

Center 

November 2012 91


In addition to the important contributions of each panel member, the panel would like to thank the 

following organizations, committees and councils who also provided data, input and information 

into the process. 

 

 

Organizations 

o Alliance for Lupus Research 

o American Autoimmune Related Diseases Association 

o Arthritis Foundation 

o Arthritis National Research Foundation 

o Autoimmunity Centers of Excellence 

o Crohn's and Colitis Foundation 

o Lupus Foundation of America 

o National Institutes of Health 

o National Psoriasis Foundation 

o Scleroderma Foundation 

o Sjogren’s Syndrome Foundation 

o Vasculitis Foundation 

Committees and Councils 

o ACR Committee on Education 

o ACR Committee on Rheumatologic Care 

o ACR Government Affairs Committee 

o ACR Committee on Quality of Care 

o ACR Registry and Health Information Technology Committee 

 

ACR Staff 

o Mark Andrejeski 

o Steven Echard 

o Steve Blevins 

o Donna Hoyne 

o Rachel Myslinski 

o LaTanya Benford 

o 

o 

o 

o 

o 

o 

Norman Kwong 

Antanya Chung 

Amy Miller 

Adam Cooper 

Damian Smalls 

Nat Cabrera 

November 2012 92


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