Realizing a learning health system through process, rigor and culture change

Using a participatory approach to identify priorities to advance LHS implementation at an academic medical center

Introduction

Like many other academic medical centers, the University of Alabama at Birmingham (UAB) aspires to adopt learning health system (LHS) principles and practices more fully. Applying LHS principles establishes a culture where clinical and operational practices constantly generate questions and leverage information technology (IT) and methodological expertise to facilitate systematic evaluation of care delivery, health outcomes, and the effects of improvement initiatives. Despite the potential benefits, differences in priorities, timelines, and expectations spanning an academic medical center's clinical care, administrative operations, and research arms create barriers to adopting and implementing an LHS.

Methods

UAB's Center for Outcomes and Effectiveness Research and Education, in partnership with UAB Medicine's Department of Clinical Practice Transformation, applied part of the Precision Problem Solving methodology to advance the implementation of LHS principles at UAB.

Results

Sixty-two stakeholders across the UAB health system and academic schools noted 131 concerns regarding the development of an LHS at UAB. From the 131 items, eight major themes were identified, named, and prioritized through a series of focus groups. Of the eight major themes, "Creating a Structure for Aligned and Informed Prioritization" and "Right Data, Right Time, Improved Performance" ranked in the top three most important themes across all focus groups and became the critical priorities as UAB enhances its LHS. A task force comprised of diverse constituents from across UAB's academic medical center is taking first steps toward addressing these priority areas. Initial funding supports a prototype for enhanced health system data access and pilot projects conducted by researchers embedded in health system teams.

Conclusion

We suggest that our experience conducting a deliberate process with broad engagement across both the health system and academic arms of the university may be informative to others seeking to advance LHS principles at academic health centers across a myriad of settings.

Understanding the training, mentorship, and professional development priorities of early career embedded researchers

INTRODUCTION

Health systems are constantly evolving in response to existing and emerging health challenges and are increasingly adopting the Quintuple Aim to guide transformation and improvement efforts. Addressing health challenges and achieving the Quintuple Aim (enhancing patient experience, improving healthcare provider experience, promoting population health, optimising the value of healthcare services, and advancing health equity) may be enhanced with the use of a Learning Health Systems approach that fosters the real-time use of data and evidence to inform improvement efforts and harnesses embedded researchers to co-produce timely, relevant evidence to address priorities. Training programs have emerged to build embedded research capacity within health system organisations and have focused predominantly on the postdoctoral career stage, with little attention paid to the early career researcher (ECR) stage. The objective of this study was to understand ECR training and mentorship needs in the embedded research context to inform the creation new or adaptation of existing programs to build embedded ECR capacity.

METHODS

This study used a qualitative approach to garner insight from embedded and applied scholars and health systems leaders in Canada from various professional backgrounds and at various career stages using a combination of focus group discussions, key informant interviews, and an online survey. Thematic content analysis was used to examine the responses of study participants within the interview themes.

RESULTS

Twenty-six (26) participants were included in the study. Results were organised according to four key themes: (1) key competencies and skills needed by embedded ECRs; (2) additional training and capacity development needs; (3) training delivery approaches; and (4) enablers and challenges faced by embedded ECRs. Results highlight the importance of supporting ECRs to develop their leadership and organisational management capabilities; their knowledge of and ability to use research approaches that are well-suited to real-world, complex, evolving environments; and their opportunities to learn with and from each other and mentors. Results underscore the perceived importance of context, including being embedded in a supportive environment that values research and evidence and of academic incentives that recognise and value real-world research impact. The challenges of responding to shifting organisational and system priorities were identified. Additional insights from health systems leaders were also highlighted.

CONCLUSION

This study identified the multifaceted needs of embedded ECRs and the challenges they face within healthcare systems. Designing new programs or tailoring existing ones to address these needs would build their capacity, foster career progression, and ensure their impact as leaders of evidence-informed health system improvement which is crucial for achieving the Quintuple Aim.

Funding Learning Health System Research: Challenges and Strategies

PURPOSE

A growing number of health systems are establishing learning health system (LHS) programs, where research focuses on rapidly improving the health system's internal operations and performance. The authors examine funding challenges facing such initiatives and identify strategies for managing tensions between reliance on external research funding and directly contributing to improvement and learning within the researchers' own system.

METHOD

Qualitative case studies of LHS research programs in 5 health systems were performed via 38 semistructured interviews (October 2019-April 2021) with 35 diverse respondents. Inductive and deductive rapid qualitative analysis supported interview, system-level, and cross-system summaries and analysis.

RESULTS

External funding awards to LHS researchers facilitated some internal improvement and learning, scientific advancements, and the reputation of researchers and their systems, but reliance on external funding also challenged researchers' responsiveness to concerns of system leaders, managers, practitioners, and system needs. Gaps between external funding requirements and internally focused projects arose in objectives, practical applicability, audiences, timetables, routines, skill sets, and researchers' careers. To contribute more directly to system improvement, LHS researchers needed to collaborate with clinicians and other nonresearchers and pivot between long research studies and shorter, dynamic improvement, evaluation, and data analysis projects. With support from system executives, LHS program leaders employed several strategies to enhance researchers' internal contributions. They aligned funded-research topics with long-term system needs, obtained internal funding for implementing and sustaining practice change, and diversified funding sources.

CONCLUSIONS

To foster LHS research contributions to internal system learning and improvement, LHS program leaders need to manage tensions between concentrating on externally funded research and fulfilling their mission of providing research-based services to their own system. Health system executives can support LHS programs by setting clear goals for them; appropriately staffing, budgeting, and incentivizing LHS researchers; and developing supportive, system-wide teamwork, skill development programs, and data infrastructures.

21st century (clinical) decision support in nursing and allied healthcare. Developing a learning health system: a reasoned design of a theoretical framework

In this paper, we present a framework for developing a Learning Health System (LHS) to provide means to a computerized clinical decision support system for allied healthcare and/or nursing professionals. LHSs are well suited to transform healthcare systems in a mission-oriented approach, and is being adopted by an increasing number of countries. Our theoretical framework provides a blueprint for organizing such a transformation with help of evidence based state of the art methodologies and techniques to eventually optimize personalized health and healthcare. Learning via health information technologies using LHS enables users to learn both individually and collectively, and independent of their location. These developments demand healthcare innovations beyond a disease focused orientation since clinical decision making in allied healthcare and nursing is mainly based on aspects of individuals' functioning, wellbeing and (dis)abilities. Developing LHSs depends heavily on intertwined social and technological innovation, and research and development. Crucial factors may be the transformation of the Internet of Things into the Internet of FAIR data & services. However, Electronic Health Record (EHR) data is in up to 80% unstructured including free text narratives and stored in various inaccessible data warehouses. Enabling the use of data as a driver for learning is challenged by interoperability and reusability.To address technical needs, key enabling technologies are suitable to convert relevant health data into machine actionable data and to develop algorithms for computerized decision support. To enable data conversions, existing classification and terminology systems serve as definition providers for natural language processing through (un)supervised learning.To facilitate clinical reasoning and personalized healthcare using LHSs, the development of personomics and functionomics are useful in allied healthcare and nursing. Developing these omics will be determined via text and data mining. This will focus on the relationships between social, psychological, cultural, behavioral and economic determinants, and human functioning.Furthermore, multiparty collaboration is crucial to develop LHSs, and man-machine interaction studies are required to develop a functional design and prototype. During development, validation and maintenance of the LHS continuous attention for challenges like data-drift, ethical, technical and practical implementation difficulties is required.

Implementation strategies and outcome measures for advancing learning health systems: a mixed methods systematic review

BACKGROUND

Learning health systems strive to continuously integrate data and evidence into practice to improve patient outcomes and ensure value-based healthcare. While the LHS concept is gaining traction, the operationalization of LHSs is underexplored.

OBJECTIVE

To identify and synthesize the existing evidence on the implementation and evaluation of advancing learning health systems across international health care settings.

METHODS

A mixed methods systematic review was conducted. Six databases (CINAHL, Embase, Medline, PAIS, Scopus and Nursing at Allied Health Database) were searched up to July 2022 for terms related to learning health systems, implementation, and evaluation measures. Any study design, health care setting and population were considered for inclusion. No limitations were placed on language or date of publication. Two reviewers independently screened the titles, abstracts, and full texts of identified articles. Data were extracted and synthesized using a convergent integrated approach. Studies were critically appraised using relevant JBI critical appraisal checklists.

RESULTS

Thirty-five studies were included in the review. Most studies were conducted in the United States (n = 21) and published between 2019 and 2022 (n = 24). Digital data capture was the most common LHS characteristic reported across studies, while patient engagement, aligned governance and a culture of rapid learning and improvement were reported least often. We identified 33 unique strategies for implementing LHSs including: change record systems, conduct local consensus discussions and audit & provide feedback. A triangulation of quantitative and qualitative data revealed three integrated findings related to the implementation of LHSs: (1) The digital infrastructure of LHSs optimizes health service delivery; (2) LHSs have a positive impact on patient care and health outcomes; and (3) LHSs can influence health care providers and the health system.

CONCLUSION

This paper provides a comprehensive overview of the implementation of LHSs in various healthcare settings. While this review identified key implementation strategies, potential outcome measures, and components of functioning LHSs, further research is needed to better understand the impact of LHSs on patient, provider and population outcomes, and health system costs. Health systems researchers should continue to apply the LHS concept in practice, with a stronger focus on evaluation.

Adapting an Interdisciplinary Learning Health System Framework for Academic Health Centers: A Scoping Review

PURPOSE

Learning health systems (LHSs), defined as a systematic process for aligning science, informatics, and clinical practice to integrate providers, researchers, and patients as active participants in an evidence-based care continuum, can provide an ideal environment for academic health centers to rapidly adopt evidence-based guidelines and translate research into practice. However, few LHS frameworks are specifically adapted for academic health centers. The authors wanted to identify the definitions, components, and other features of LHSs to develop an interdisciplinary LHS framework for use within academic health centers.

METHOD

The authors conducted a scoping review of the literature to identify definitions, components, and other features of LHSs that are useful to academic health centers. In January 2021, they searched PubMed, Academic Search Premier, and Scopus databases and identified English-language, peer-reviewed articles pertaining to LHS, LHS frameworks, organization, components, and models. Since the phrase learning health system is relatively new terminology, they conducted a supplemental review with alternative phrases, including embedded research and coordinated or collaborative research network . They used the Knowledge to Action (KTA) Framework to integrate the generation and flow of research into practice.

RESULTS

The primary review retrieved 719 articles and the supplemental review retrieved 209; of these, 49 articles were retained to synthesize common definitions, components, and other features of LHS frameworks. Seven structural components of LHSs were identified: organization and collaborations, performance, ethics and security, scientific approaches, data, information technology, and patient outcomes. An adapted interdisciplinary LHS framework was developed that incorporated research and learning engines derived from the KTA and adaptations of common components and other features within the reviewed articles to fit the interests of providers, researchers, and patients within academic health centers.

CONCLUSIONS

The adapted LHS framework can be used as a dynamic foundation for development and organization of interdisciplinary LHSs within academic health centers.

A systems thinking approach for antimicrobial stewardship in primary care

INTRODUCTION

The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care.

AREAS COVERED

The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries.

EXPERT OPINION

The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.