Learning health systems

Learning health systems (LHS) are healthcare systems in which knowledge generation processes are embedded in daily practice to produce continual improvement in care.[1][2][3]

The idea was first conceptualised in a 2007 workshop organised by the US Institute of Medicine, building on ideas around evidence-based medicine[1] and "practice-based evidence".[4] There has since been increasing interest in the topic, including the creation of the Wiley journal Learning Health Systems.[3]

LHS can be described as having four key elements:

1. an organizational architecture that supports the formation of communities of patients, healthcare professionals and researchers who collaborate to produce and use "big data";
2. large electronic health data sets, i.e. "big data";
3. quality improvement at the point of care for each patient using new knowledge generated by research;
4. research done in routine healthcare settings.[5]

They are thus dependent on the use of electronic health records (EHRs) and have inherited the adoption challenges of EHRs.[6]

LHS entails a clinical lifecycle. Patient data is collected, it is amalgamated across multiple patients and a problem is defined.[7] These are activities largely driven by healthcare professionals. With the support of technology, an analysis is performed, which returns evidence, from which knowledge is generated, which leads to changed clinical practice, and thus to new patient data being collected.[3][8][9]

McLachlan and colleagues (2018) suggest a taxonomy of nine LHS classification types:[3]

1. Cohort identification looks for patients with similar attributes.[10]
2. Positive deviance finds examples of better care against a benchmark.[11]
3. Negative deviance finds examples of sub-optimal care.[12]
4. Predictive patient risk modeling uses patterns in data to find groups at greater risk of adverse events.[13]
5. Predictive care risk and outcome models identify situations that are at greater risk of poor care.[14]
6. Clinical decision support systems use patient algorithms applied to patient data to make specific treatment recommendations.
7. Comparative effectiveness research determines the most effective treatments.[14]
8. Intelligent assistance use data to automate routine processes.[14]
9. Surveillance monitors data for disease outbreaks or other treatment issues.[15]

Next Generation of Learning Health Systems Researchers: The Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI) have awarded $40 million in grants over 5 years to 11 institutions to support the training of clinician and research scientists to conduct patient-centered outcomes research within LHS.[16][17]

The LHS Centers of Excellence are:[18]

1. A Chicago Center of Excellence in Learning Health Systems Research Training (ACCELERAT), Northwestern University, Chicago, Ill.
2. CATALyST: Consortium for Applied Training to Advance the Learning Health System with Scholars/Trainees, Kaiser Permanente Washington Health Research Institute, Seattle, Wash.[19]
3. Learning Health System Scholar Program at Vanderbilt, Vanderbilt University, Nashville, Tenn.
4. Leveraging Infrastructure to Train Investigators in Patient-Centered Outcomes Research in Learning Health System (LITI- PCORLHS), Indiana University School of Medicine, Indianapolis, Ind.[20]
5. Minnesota Learning Health System Mentored Career Development Program (MN-LHS), University of Minnesota, Minneapolis, Minnesota.[21]
6. Northwest Center of Excellence & K12 in Patient Centered Learning Health Systems Science, Oregon Health and Science University, Portland, Oregon.[22]
7. PEDSnet Scholars: A Training Program for Pediatric Learning Health System Researchers, Children’s Hospital of Philadelphia, Philadelphia, Pa [23]
8. Stakeholder-Partnered Implementation Research and Innovation Translation (SPIRIT) program, University of California Los Angeles, Los Angeles, California.[24]
9. The Center of Excellence in Promoting LHS Operations and Research at Einstein/Montefiore (EXPLORE), Albert Einstein College of Medicine, Bronx, N.Y.
10. Transforming the Generation and Adoption of PCOR into Practice (T-GAPP), University of Pennsylvania, Philadelphia, Pa.
11. University of California-San Francisco Learning Health System K12 Career Development Program, University of California San Francisco, San Francisco, California.

See also

• Real World Evidence

References

1. "The Learning Healthcare System: Workshop Summary", edited by Olsen L, Aisner D, McGinnis JM, Institute of Medicine (US) ISBN 978-0-309-10300-8
2. Institute of Medicine. "Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care." Washington, DC: Institute of Medicine, 2011. ISBN 0-309-15416-2
3. McLachlan S, Potts HWW, Dube K, Buchanan D, Lean S, Gallagher T, Johnson O, Daley B, Marsh W, Fenton N. "The Heimdall framework for supporting characterisation of learning health systems." J Innov Health Inform 2018;25(2):77–87. doi:10.14236/jhi.v25i2.996
4. Greene, S, and A Geiger. 2006. "A review finds that multicenter studies face substantial challenges but strategies exist to achieve Institutional Review Board approval." Journal of Clinical Epidemiology 59(8):784-790.
5. Forrest C, Margolis P, Seid M and Colletti RB. PEDSnet: how a prototype pediatric learning health system is being expanded into a national network. Health Affairs 2014;33(7):1171–7
6. McLachlan S, Dube K, Johnson O, Buchanan D, Potts HWW, Gallagher T, Fenton N. "A framework for analyzing learning health systems: Are we removing the most impactful barriers?" Learning Health Systems 2019: e10189. doi:10.1002/lrh2.10189
7. "From Patient Data to Medical Knowledge: The Principles and Practice of Health Informatics" by Paul Taylor, Blackwell Publishing Ltd., 2007
8. Deeny S and Steventon A. Making sense of the shadows: Priorities for creating a learning healthcare system based on routinely collected data. BMJ Quality Safety 2015;24:505–15. doi:10.1136/bmjqs-2015-004278
9. Abernethy A, Ahmad A, Zafar SY, Wheeler JL, Reese JB and Lyerly HK. Electronic patient-reported data capture as a foundation of rapid learning cancer care. Medical Care 2010;48(6):S32–8. doi:10.1097/MLR.0b013e3181db53a4
10. Friedman C, Wong A and Blumenthal D. Achieving a nationwide learning health system. Science Transitional Medicine 2010;2(57):1–3
11. Bradley E, Curry LA, Ramanadhan S, Rowe L, Nembhard IM and Krumholz HM. Research in action: using positive deviance to improve quality of health care. BMC Implementation Science 2009;4:25.
12. Deeny S and Steventon A. Making sense of the shadows: Priorities for creating a learning healthcare system based on routinely collected data. BMJ Quality Safety 2015;24:505–15.
13. Lewis G, Kirkham H and Vaithianathan R. How health systems could avert ‘triple fail’ events that are harmful, are costly, and result in poor patient satisfaction. Health Affairs 2013;32(4):669–76
14. Foley T and Vale L. What role for learning health systems in quality improvement within healthcare providers? Learning Health Systems 2017;1(4).
15. Ye Y, Wamukoya M, Ezeh A, Emina JB and Sankoh O. Health and Demographic Surveillance Systems: a step towards full civil registration and vital statistics in sub-Saharan Africa? BMC Public Health 2012;12:741.
16. Agency for Healthcare Research and Quality. Supporting the Next Generation of Learning Health Systems Researchers [Internet]. 2018. Available from: https://www.ahrq.gov/funding/training-grants/lhs-k12.html
17. Patient-Centered Outcomes Research Institute. Supporting the Next Generation of Learning Health Systems Researchers [Internet]. Available from: https://www.pcori.org/research-results/2017/supporting-next-generation-learning-health-systems-researchers
18. Agency for Healthcare Research and Quality. Supporting the Next Generation of Learning Health Systems Researchers [Internet]. 2018. Available from: https://www.ahrq.gov/news/newsroom/press-releases/next-generation-lhs-researchers.html
19. Kaiser Permanente Washington Health Research Institute. CATALyST LHS K12 - Train in Learning Health System Research [Internet]. Available from: https://www.kpwashingtonresearch.org/about-us/careers/catalyst-k12-washington-learning-health-system-scholar-program
20. Regenstrief Institute. IU-Regenstrief 1 of 11 Awards for Next Generation of Learning Health System Researchers [Internet]. Available from: https://www.regenstrief.org/article/iu-regenstrief-ahrq-award/
21. University of Minnesota. Minnesota Learning Health System [Internet]. Available from: https://www.sph.umn.edu/research/projects/minnesota-learning-health-system/
22. Oregon Health & Science University. NW Center of Excellence and K12 in Learning Health Systems Science [Internet]. Available from: https://www.ohsu.edu/pact-k12
23. PEDSnet. PEDSnet Scholars: A Career Development Program for Junior Faculty Interested in Learning Health Systems Research [Internet]. Available from: https://pedsnet.org/pedsnet-scholars/.
24. University of California, Los Angeles. SPIRIT K12 Center of Excellence in Learning Health System Researcher Training [Internet]. Available from: https://www.uclahealth.org/internal-medicine/spirit-k12-program