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

Four distinct models of learning health systems: Strength through diversity

The concept of a learning health system (LHS) was established nearly 20 years ago as a unifying commitment to speed the generation and use of evidence primarily by leveraging rapid advances in data and technologies, resulting in optimized care for each patient. In the ensuing decades, vanguard adopters of the LHS who have sought to move the LHS from conceptual to operational have done so in ways that fit with and reflect their organizational structure, mission, and culture-as well as their personal values and experiences. They have also extended the focus from health care to include individual and population health more broadly. This commentary describes four distinctive models that have evolved as learning health system activities have matured. Viewing this diversity as a strength, the features, commonalities, and unique differences of these models are described.

Development of a curriculum to educate religious leaders about blood pressure using community-based participatory research and educational theory in Mwanza, Tanzania

Hypertension is a leading cause of premature mortality in Tanzania, but low trust and awareness of biomedical healthcare and prioritization of spiritual over physical health hinders uptake of care. Religious leaders are highly respected community members and are eager to collaborate with health professionals. Few community health worker training programs utilize evidence-based pedagogical recommendations in combination with theology specific to their students' backgrounds. Our team of health research professionals and religious leaders developed a curriculum to teach local religious leaders to address and screen their communities for hypertension.We use a Community Based Participatory Research framework and evidence-based educational strategies (Kern's framework for medical education, Bloom's learning domains, and Knowles adult learning principles) to build a curriculum optimized to partner with religious leaders. Previously assessed attitudes toward and knowledge of hypertension in the community determined objectives and content, and religious leaders on the team determined appropriate religious aspects to incorporate. Through an evidence-based process, we hope to maximize efficacy of the intervention.Recognizing religious leaders as unique learners, we utilize well-tested educational theory and strategies to create a comprehensive curriculum prioritizing student input. The curriculum aligns with adult learning theories, is culturally tailored to meet the needs of the communities involved and equips religious leaders to promote blood pressure management through screening and lifestyle interventions. The curriculum addresses healthcare through a religious lens, fostering trust between healthcare professionals, patients, and religious leaders through interdisciplinary collaboration.

Towards a shared understanding of the learning health system in a large academic-based health system: A qualitative analysis

Healthcare delivery is currently undergoing major structural reform, and the Learning Health System (LHS) has been proposed as an aspirational model to guide healthcare transformation. As efforts to build LHS take considerable investment from health systems, it is critical to understand their leaders' perspectives on the rationale for pursuing an LHS and the potential benefits for doing so. This paper describes the qualitative analysis of semi-structured interviews (n = 17) with health system leaders about their general perceptions of the LHS, description of key attributes and potential benefits, and perception of barriers to and facilitators for advancing the model. Participants universally endorsed the goal of the local health system aspiring to become an LHS. Participants identified many recognized attributes of LHS, though they emphasized unique attributes and potential benefits. There was also heterogeneity in participants' views on what to prioritize, how to structure the local LHS within existing initiatives, and how new initiatives should be implemented. Improving conceptual clarity of attributes of the LHS would improve its potential in guiding future reform.

Patient safety is our business! Staff perspectives on implementing hospital falls prevention education

Providing patients with falls prevention education reduces falls in hospitals, yet there is limited research on what influences successful implementation at the staff, ward and hospital levels. We engaged hospital-based health professionals to identify multi-level barriers and enablers to patient falls education that could influence the implementation of a Safe Recovery program. Purposive sampling was used to recruit hospital staff (n = 40) for focus groups and one-on-one interviews. Data were analysed using content analysis and categorized using a socio-ecological framework to understand the micro, meso and macro level influences of hospital falls prevention. We identified five overarching themes, on the barriers and enablers to implementation of the Safe Recovery program. The enablers to falls prevention education included sharing the responsibility to implement the program, setting clear goals for staff, showing the impact of delivering the program, involving family to reinforce the messaging, using falls champions to upskill staff and making the resources (video and booklet) readily available to patients at all times. Barriers included insufficient time for staff to deliver falls prevention education, lack of falls prevention training for staff during their clinical training, absence of standardized protocols and clinical guidelines across hospital settings and insufficient hospital marketing to promote the program. Using a systems thinking approach, this study showed that implementation requires more advocacy and support for patient falls prevention across different tiers of the hospital system to integrate into usual care.

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.

The power of personas: Exploring an innovative model for understanding stakeholder perspectives in an oncology learning health network

Introduction

Learning health networks (LHNs) improve clinical outcomes by applying core tenets of continuous quality improvements (QI) to reach community-defined outcomes, data-sharing, and empowered interdisciplinary teams including patients and caregivers. LHNs provide an ideal environment for the rapid adoption of evidence-based guidelines and translation of research and best practices at scale. When an LHN is established, it is critical to understand the needs of all stakeholders. To accomplish this, we used ethnographic methods to develop personas of different stakeholders within The Canopy Cancer Collective, the first oncology LHN.

Methods

We partnered with a firm experienced in qualitative research and human-centered design to conduct interviews with stakeholders of The Canopy Cancer Collective, a newly developed pancreatic cancer LHN. Together with the firm, we developed a personas model approach to represent the wide range of diverse perspectives among the representative stakeholders, which included care team members, patients, and caregivers.

Results

Thirty-one stakeholders from all facets of pancreatic cancer care were interviewed, including 20 care team members, 8 patients, and 3 caregivers. Interview transcripts were analyzed to construct 10 personas felt to represent the broad spectrum of stakeholders within The Cancer Canopy Collective. These personas were used as a foundation for the design and development of The Cancer Canopy Cancer Collective key drivers and aims.

Conclusions

As LHNs continue to facilitate comprehensive approaches to patient-centered care, interdisciplinary teams who understand each other's needs can improve Network unity and cohesion. We present the first model utilizing personas for LHNs, demonstrating this framework holds significant promise for further study. If validated, such an approach could be used as a dynamic foundation for understanding individual stakeholder needs in similar LHN ecosystems in the future.

Relevance of learning health systems to physiatrists and its synergy with implementation science: A commentary

As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs.

Psychiatric Hospitals and the Ethics of Salutogenic Design: The Return of Moral Architecture?

ABSTRACT

Bioethicists have long been concerned with the mistreatment of institutionalized patients, including those suffering from mental illness. Despite this attention, the built environments of health care settings have largely escaped bioethical analysis. This is a striking oversight given that architects and social scientists agree that buildings reflect and reinforce prevailing social, cultural, and medical attitudes. Architectural choices are therefore ethical choices. We argue that mental health institutions are fertile sites for ethical analysis. Examining the ethics of architecture calls attention to the potential for hospitals to hinder autonomy. Additionally, such examination highlights the salutogenic possibilities of institutional design, that is to care, nurture, and enhance patient and provider well-being.

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.

Efficacy of Digital Outreach Strategies for Collecting Smoking Data: Pragmatic Randomized Trial

BACKGROUND

Tobacco smoking is an important risk factor for disease, but inaccurate smoking history data in the electronic medical record (EMR) limits the reach of lung cancer screening (LCS) and tobacco cessation interventions. Patient-generated health data is a novel approach to documenting smoking history; however, the comparative effectiveness of different approaches is unclear.

OBJECTIVE

We designed a quality improvement intervention to evaluate the effectiveness of portal questionnaires compared to SMS text message-based surveys, to compare message frames, and to evaluate the completeness of patient-generated smoking histories.

METHODS

We randomly assigned patients aged between 50 and 80 years with a history of tobacco use who identified English as a preferred language and have never undergone LCS to receive an EMR portal questionnaire or a text survey. The portal questionnaire used a "helpfulness" message, while the text survey tested frame types informed by behavior economics ("gain," "loss," and "helpfulness") and nudge messaging. The primary outcome was the response rate for each modality and framing type. Completeness and consistency with documented structured smoking data were also evaluated.

RESULTS

Participants were more likely to respond to the text survey (191/1000, 19.1%) compared to the portal questionnaire (35/504, 6.9%). Across all text survey rounds, patients were less responsive to the "helpfulness" frame compared with the "gain" frame (odds ratio [OR] 0.29, 95% CI 0.09-0.91; P<.05) and "loss" frame (OR 0.32, 95% CI 11.8-99.4; P<.05). Compared to the structured data in the EMR, the patient-generated data were significantly more likely to be complete enough to determine LCS eligibility both compared to the portal questionnaire (OR 34.2, 95% CI 3.8-11.1; P<.05) and to the text survey (OR 6.8, 95% CI 3.8-11.1; P<.05).

CONCLUSIONS

We found that an approach using patient-generated data is a feasible way to engage patients and collect complete smoking histories. Patients are likely to respond to a text survey using "gain" or "loss" framing to report detailed smoking histories. Optimizing an SMS text message approach to collect medical information has implications for preventative and follow-up clinical care beyond smoking histories, LCS, and smoking cessation therapy.

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.