In over half of the studies (27/53, 50.9%), the implemented LHS involved examination and use of data from electronic health records, clinical registries, or other routinely collected data sources. Jeffries M, Keers RN, Phipps DL, Williams R, Brown B, Avery AJ, Peek N, Ashcroft DM. The search identified a total of 529 citations. Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks. Despite all the resourcefulness and efforts internationally, health care performance has, by and large, flatlined, with persisting iatrogenic harm, inefficiencies, and health care waste [2,3]. This likely reflects that LHSs remain a relatively new service model that has not been widely implemented in a cohesive way over the longer term to be concerned with assessing the sustainability and penetration of LHS programs, systems, and platforms. As a library, NLM provides access to scientific literature. Barned C, Dobson J, Stintzi A, Mack D, O'Doherty KC. IEEE; 2016. pp. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Glasgow RE, Battaglia C, McCreight M, Ayele RA, Rabin BA. Car J, Sheikh A, Wicks P, Williams MS. The primary study concern or focus was inductively classified by 2 authors (LAE and MS) into 1 of 4 classifications: (1) specific programs, systems, and platforms; (2) ethics, policies, and governance; (3) stakeholder perspectives of LHSs; and (4) LHS-specific research strategies and tools. government site. 2-5 The Institute of Medicine 6 defines an LHS as a system "in which science, informatics, incentives, and culture are aligned for . However, at the same time, it is important for a pragmatic approach to be undertaken, in which implementation science frameworks may be used flexibly but pragmatically to guide rapid-cycle design and analysis. Geisinger documented its efforts to improve patient-clinician engagement with patient-reported experience measures (PREMS) serving as the primary metric for measuring success, moving Geisinger into closer alignment with the LHS vision [11]. It is timely to look more closely at the published empirical research and to ask the question, Where are we now? McWilliams A, Schoen M, Krull C, Bilancia J, Bacon M, Pena E, McCall A, Howard D, Roberge J. Although PDSA cycles may be useful to identify whether an approach or intervention is effective, more timely feedback is needed to inform how and why an intervention is successful or unsuccessful [18]. For this review, which focused further on the implementation of an LHS, implementation determinants were defined as barriers and enablers that may prevent or facilitate, respectively, improvements in practice [22], as reported in the included studies. Congratulations to Tom Foley and his co-authors on the publication of 'Realising the Potential of Learning Health Systems', from The Health Foundation and There is increasing international policy and clinical interest in developing learning health systems and delivering precision medicine, which it is hoped will help reduce variation in the quality and safety of care, improve efficiency, and lead to increasing the personalisation of healthcare. Federal government websites often end in .gov or .mil. These included having complex systems knowledge, having expertise in implementation science and informatics, knowing when and how to use mixed-methods designs, and ensuring the engagement of all relevant stakeholders (eg, patients, clinicians) [79]. Over two-thirds of the program-specific studies utilized quantitative methods (37/53, 69.8%), with a smaller number utilizing qualitative methods (10/53, 18.9%) or mixed-methods designs (6/53, 11.3%). This will enrich our understanding of how to make progress toward an LHS. Porat T, Marshall IJ, Sadler E, Vadillo MA, McKevitt C, Wolfe CDA, Curcin V. Collaborative design of a decision aid for stroke survivors with multimorbidity: a qualitative study in the UK engaging key stakeholders. There may be equivalent terms used in other parts of the world, and in other languages other than English, that should be explored in future reviews. Traditional PDSA models, utilized to address the need for timely feedback within an LHS, have almost exclusively focused on quantitative patient data or process metrics [18]. It wouldve been nice if they interpreted the data a little bit. May 17, 2021 Reports This report offers guidance for building a Learning Health System, focusing on tools, models and frameworks that might be helpful. Mukherjee M, Cresswell K, Sheikh A. Identifying strategies to overcome roadblocks to utilising near real-time healthcare and administrative data to create a Scotland-wide learning health system. 2022 August; 10(8): e41424, https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-01563-4, http://europepmc.org/abstract/MED/25342177, http://qualitysafety.bmj.com/lookup/pmidlookup?view=long&pmid=29438072, https://linkinghub.elsevier.com/retrieve/pii/S1532-0464(16)30131-9, https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06215-8, http://europepmc.org/abstract/MED/27163980, https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1382-x, http://europepmc.org/abstract/MED/20957426, https://gdt.gradepro.org/app/handbook/handbook.html#h.hnedbo8gqjqk, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups, http://europepmc.org/abstract/MED/27280328, http://europepmc.org/abstract/MED/29881737, http://europepmc.org/abstract/MED/30602195, https://dx.plos.org/10.1371/journal.pone.0177102, https://implementationsciencecomms.biomedcentral.com/articles/10.1186/s43058-020-00053-1, https://implementationscience.biomedcentral.com/articles/10.1186/s13012-020-0976-1, https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-016-0122-3, https://bmjopen.bmj.com/lookup/pmidlookup?view=long&pmid=28385912, https://bmjopen.bmj.com/lookup/pmidlookup?view=long&pmid=31420396, https://dx.plos.org/10.1371/journal.pone.0205419, https://linkinghub.elsevier.com/retrieve/pii/S1553-7250(20)30234-8, https://implementationscience.biomedcentral.com/articles/10.1186/s13012-020-0972-5, https://linkinghub.elsevier.com/retrieve/pii/S2451-8654(18)30132-7, http://europepmc.org/abstract/MED/31233126, https://linkinghub.elsevier.com/retrieve/pii/S1532-0464(16)00006-X, http://europepmc.org/abstract/MED/33409427, http://europepmc.org/abstract/MED/26718665, https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-4-50, https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0343-9, http://europepmc.org/abstract/MED/27917391, https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-017-0185-x, http://europepmc.org/abstract/MED/31367650, http://europepmc.org/abstract/MED/27683668, https://journals.sagepub.com/doi/10.1177/1460458220977579?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed, http://europepmc.org/abstract/MED/28777456, https://bmjopen.bmj.com/lookup/pmidlookup?view=long&pmid=33371049, https://dx.plos.org/10.1371/journal.pmed.1002288, http://europepmc.org/abstract/MED/22310560, https://implementationscience.biomedcentral.com/articles/10.1186/s13012-019-0892-4, https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05289-0, Health care professionals satisfaction with various aspects of the LHS initiative (eg, content, complexity, comfort, delivery, and credibility), Fit, relevance, compatibility, suitability, usefulness, and practicability perceived by health care professionals and patients, The actual fit, utility, and practicability of the program within a health service setting and its subsystems, as reported by health care professionals and managers, The LHS initiative delivered, as intended; adherence by health care professionals; and quality of program delivery, Financial impact of LHS implementation to the health service or organization, Spread or reach of the LHS initiative assessed at the organization or setting level, The extent to which the LHS program is maintained or institutionalized within a health services standard operations, Consolidated Framework for Implementation Research, Grading of Recommendations Assessment, Development and Evaluation, Preferred Reporting Items of Systematic Review and Meta-Analyses Extension for Scoping Reviews, Reach, Effectiveness, Adoption, Implementation, and Maintenance. Change resistance, resource constraints, and concerns regarding centralized decision making were prominent barriers to the ability to transform care delivery [34,35]. A Learning Health System (LHS) is one "in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience" (Institute of Medicine, 2007). Taking an "implementation science" lens, the review aims to map out the empirical research that has been conducted to date, identify limitations, and identify future directions for the field. Colors represent different topic areas. This will be different for each organisation. Based on the full-text assessment, a further 13 (14.6%) of 89 studies did not meet the inclusion criteria, and hence 76 (85.4%) studies were included in this review (Figure 2). After removing duplicates, 509 (96.2%) remained for title/abstract review. Brown-Johnson C, Safaeinili N, Zionts D, Holdsworth LM, Shaw JG, Asch SM, Mahoney M, Winget M. The Stanford Lightning Report Method: a comparison of rapid qualitative synthesis results across four implementation evaluations. Smith J, Rapport F, O'Brien TA, Smith S, Tyrrell VJ, Mould EV, Long JC, Gul H, Cullis J, Braithwaite J. It does however, present a framework for considering the key challenges facing anyone building a Learning Health System, whether at a local, regional, national or international scale. The size of the node indicates the number of times a keyword was used. Although none of these studies examined implementation effectiveness, each study explored broad ethical, policy, or governance barriers and enablers to achieving an LHS. Meyer AN, Upadhyay DK, Collins CA, Fitzpatrick MH, Kobylinski M, Bansal AB, Torretti D, Singh H. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Kunjan K, Doebbeling B, Toscos T. Dashboards to support operational decision making in health centers: a case for role-specific design. Study information was extracted relevant to the review objective, including each studys publication details; primary concern or focus; context; design; data type; implementation framework, model, or theory used; and implementation determinants or outcomes examined. This progression from the predominantly theoretical contributions to the LHS literature to more applied and empirical evaluations has begun to uncover the potential methodological flaws and limitations of data systems in realizing the promise of an LHS. A systematic review. The Institute of Medicine defines a continuously 'learning health system' as one in which, 'science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.' The divide raised ethical concerns, including the potential for studies to be inappropriately classed as quality improvement in order to expedite LHS feedback loops [64] and researchers undertaking more rigorous research practices, such as randomization or implementing randomization without consent [62,65]. Shulman R, Chafe R, Guttmann A. Over two-thirds of the included studies (53/76, 69.7%) were concerned with implementing a particular program, system, or platform designed to contribute to achieving an LHS. A Just Culture environment provides benefits for patients, EMS practitioners, EMS agencies, Smith M, Vaughan-Sarrazin M, Yu M, Wang X, Nordby P, Vogeli C, Jaffery J, Metlay JP. The authors emphasized that future efforts may need to focus on optimizing the delivery of PROMs within LHSs. The rapid spread of COVID-19 added urgency to the need to address long-standing pressures on health systems, linked to growing citizens' expectations, population ageing and more complex and costly health care needs. Five (6.6%) of 76 studies described the novel development and application of LHS-specific research tools or frameworks [18,31,46,75,76], and 3 (60%) of these 5 studies outlined the development of rapid analytic tools to address the need for timely feedback and evaluation [18,46,76] and to address the limitations of traditional plan-do-study-act (PDSA) models [18]. In: Albers B, Shonsky A, Mildon R, editors. Several reviews of the topic have also now emerged, identifying limited but growing empirical LHS applications. Franklin et al [31] developed an implementation framework to guide PROM data collection, interpretation, and use. Differences in how implementation determinants and outcomes are reported diminishes the ability to identify trends and important factors across studies and complicates their use in reviews. While local uptake was positive, transformative potential will require longer-term engagement, and with higher levels of the system. The thematic analysis of the study focus led to classification into either (1) specific programs, systems, and platforms or 1 of the following key research areas: (2) ethics, policies, and governance; (3) stakeholder perspectives of LHSs; or (4) LHS-specific research strategies and tools. Understanding these barriers and enablers is a key first step toward unlocking the mechanisms that could trigger lasting improvements in how health care is delivered [87]. Building on these new opportunities, Learning Health Systems (LHS) has been proposed as a management innovation for healthcare systems to improve the quality of care, efficiency, and scaling up of innovations. In particular, we are seeing research concerned with implementing a variety of programs, systems, or platforms designed to contribute to achieving an LHS. Schnemann H, Broek J, Guyatt G, Oxman A. GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations. Learning at individual, team, organization and cross-organization levels is fundamental to health systems strengthening and the achievement of health goals. Exhibit 4. Implementation is so difficult: survey of national learning health system decision-makers identifies need for implementation information in evidence reviews. Almost three-quarters (n=55, 72.4%) of the studies were from the United States, and virtually all (n=75, 98.7%) were from high-income countries. employ them, must recognize the potential for medical errors during the provision of emergency medical services, and appreciate the subsequent learning opportunities that are created when these errors are appropriately analyzed and managed. Study protocols, review papers, journal commentaries, and editorials were excluded. All authors provided critical feedback and helped shape the final manuscript. We have focused limited attention on the review of service and patient outcomes measured and reported in the included studies, and this warrants further investigation. The keyword data was analyzed for frequency and co-occurrence and graphically presented using Gephi version 0.9.2. Network of co-occurring keywords with in-degree 2. Learning Health Systems are complex by nature, and must be co-designed with local stakeholders. For example, in the United States, well-regarded health care provider Geisinger reported on its significantly expanded informatics and science capabilities over the past 5 years by migrating its comprehensive data assets into a big data enterprise data warehouse infrastructure [11]. However, high-quality empirical research, such as randomized controlled trials and implementation evaluations, is still lacking. The review team (authors LAE, MS, CP, ZM, and IM) screened the full-text publications to determine their inclusion against criteria, and 5% of the retrieved publications were independently screened by the entire review team to ensure consistent inclusion. Ethier J, Curcin V, McGilchrist MM, Choi Keung SNL, Zhao L, Andreasson A, Brdka P, Michalski R, Arvanitis TN, Mastellos N, Burgun A, Delaney BC. The use of quantitative data alone does not produce the depth of understanding of barriers and enablers to innovation, implementation, and measurement, nor does it generate lessons with the level of granularity needed to interpret the findings across a complex LHS [46]. The report Realising the Potential of Primary Health Care, released on 2 June 2020, discusses how primary care needs to evolve to meet the challenges that OECD healthcare systems - and societies more broadly - are facing, and identifying what high performing primary care will look like ten or twenty years from now.The report in particular identifies which countries appear to be at the . The Learning Healthcare System: Workshop Summary. Convergence of implementation science, precision medicine, and the learning health care system: a new model for biomedical research. Geisinger's effort to realize its potential as a learning health system: a progress report. "It feels like a lot of extra work": resident attitudes about quality improvement and implications for an effective learning health care system. In particular, the routine use of implementation determinant and outcome frameworks will improve the assessment and reporting of barriers, enablers, and implementation outcomes in this field and will enable comparison and identification of trends across studies. Emerging developments and their implications. Realising the potential of learning health systems A Learning Health System is described as a health system in which outcomes and experience are continually improved by applying science, informatics, incentives and culture to generate and use knowledge in the delivery of care. 1 INTRODUCTION. Organizing for collaboration: an actor-oriented architecture in ImproveCareNow. In another study, Holdsworth et al [46] outlined an adapted rapid assessment procedure (RAP), which incorporates the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and CFIR implementation science frameworks, and iterative working with stakeholders, as well as rapid team analysis and triangulation of data sources [46]. Another area ripe for further study is an in-depth review of LHS frameworks and theoretical underpinnings, with an examination of how these frameworks are being applied to support the adoption of LHSs into the health system. The number of studies focused on implementing LHSs is increasing. The three numbers you need to know about healthcare: the 60-30-10 Challenge. A framework for understanding, designing, developing and evaluating Learning Health Systems. This raises the meta-question, Have the benefits of an LHS been empirically demonstrated prior to implementation? Methods These categories of focus are considered separately later. Although there is a plethora of implementation science theories, models, and frameworks available [22], their use in LHS research remains limited. Learning health systems: a review of key topic areas and bibliometric trends. Integrating qualitative research methods into care improvement efforts within a learning health system: addressing antibiotic overuse. And then my health markers changed. Ciemins EL, Mollis BL, Brant JM, Hassell LA, Albritton S, Amoroso P, Lloyd A, Smith JM, Pflugeisen BM, Tuttle KR, Baldwin L. Clinician engagement in research as a path toward the learning health system: a regional survey across the northwestern United States. . We have identified a more fundamental explanation: the majority of developments in LHS are not identified as LHS. 10. Rausch T, Judd T. Using Integrated Clinical Environment Data for Health Technology Management. Most of these studies also focused on a specific clinical context or patient population, potentially explaining why the papers were widely spread across different journals. Blog Post Realizing the Full Potential of the Learning Health System The Health Care Systems Research Network is seeking submissions to include in a forthcoming special issue of eGEMs that will serve as an evidence-informed toolkit to address the complex attributes of health and health care. Leadership perspectives on operationalizing the learning health care system in an integrated delivery system. Most of these studies focused on a particular clinical context or patient population (37/53, 69.8%), with far fewer studies focusing on whole hospital systems (4/53, 7.5%) or on other broad health care systems encompassing multiple facilities (12/53, 22.6%). Learning health systems: pathways to progress A flagship report from the Alliance for Health Policy and Systems Research 6 September 2021 | Global report Download (1.8 MB) Overview Learning - at individual, team, organization and cross-organization levels - is fundamental to health systems strengthening and the achievement of health goals. The .gov means its official. Chambers DA, Feero WG, Khoury MJ. Rapport F, Smith J, Hutchinson K, Clay-Williams R, Churruca K, Bierbaum M. Too much theory and not enough practice? An official website of the United States government. These studies examined LHS ethics, policy, and governance issues through qualitative interviews (n=3, 30%) [60-62] or focus groups (n=3, 30%) [63-65], quantitative methods (n=3, 30%) [66-68], or mixed-method designs (n=1, 10%) [69]. This study performed a scoping review of empirical research within the LHS domain. A scoping review method, which examines the extent, range, and nature of empirical work on a topic, was used to identify gaps and provide suggestions to improve future empirical research on LHSs [21]. Papers were grouped together based on extracted data (eg, study design) and summarized through narrative techniques. Floyd N, Peterson K, Christensen V, Anderson J. We map out the empirical research that has been conducted to date, identify limitations, and identify future directions for the field. By leveraging study designs that evaluate the effectiveness of LHS-specific programs, systems, and platforms simultaneously with their implementation, there is an opportunity to accelerate the generation of empirical evidence for LHSs. This report offers guidance for building a Learning Health System, focusing on tools, models and frameworks that might be helpful. First, we need to understand why we are building a Learning Health System. We aim to refresh The Potential of Learning Healthcare Systems [1], which was published in 2015. Jones B, Collingridge D, Vines C, Post H, Holmen J, Allen T, Haug P, Weir C, Dean N. CDS in a learning health care system: identifying physicians' reasons for rejection of best-practice recommendations in pneumonia through computerized clinical decision support.
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