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Learning health systems

Bridging the gap between research and practice

By Timothy Beebe, PhD

ore than one-fifth of all medical care may be unnecessary, according to a 2017 article in Health Affairs by Jason Buxbaum and colleagues. This low-value care—that is, patient care with no net benefit in specific clinical scenarios—costs patients, purchasers, and taxpayers hundreds of billions of dollars every year. The United States spends more on health care per capita than any of the world’s wealthiest countries, comprising 18% of the U.S. gross domestic product in 2017.

Work needs to be done on many fronts to change low-value care to high-value care across populations and across the country. One way to start is to bring-up-to-date, highly informed public health research to the physician in the exam room and to the patient they serve through a learning health systems (LHS) approach.

Strengthening the contributions of research to improve the care provided to patients requires embedding LHS researchers in health care systems and allowing them to engage in rapid, iterative learning about practice-relevant questions and using data to drive decision-making. Researchers in this context must balance the demand for rapidly generated, practical evidence with the rigors of peer-review and scientific standards. Classical comparative effectiveness research (CER), health services research (HSR), and patient-centered outcomes research (PCOR) approaches are ill-equipped to generate practical evidence for immediate application within health systems.

Definitions

Learning health systems, characterized by their dedication to continual improvement and innovation, strive to address unnecessary and potentially harmful variations in care to lower costs while improving care.

As part of the recently formed Minnesota Learning Health System Mentored Career Development Program (MN-LHS) scholars in multiple fields will be embedded in health systems and collaborate with their stakeholders to provide insights and evidence that can be rapidly implemented to improve both patient outcomes and health systems performance.

​The pace of traditional research lags … behind the real pace of change.

Funded with a $4 million grant from the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI), the MN-LHS is a collaboration among the University of Minnesota School of Public Health, Mayo Clinic, Hennepin Healthcare, and six other collaborating clinical sites.

The MN-LHS is one of 11 institutions with awards from AHRQ and PCORI totaling $40 million over five years to support the training of researchers to conduct patient-centered outcomes research within learning health systems.

Background

The need. Health systems face a complex web of imperatives, which in turn present opportunities to conduct applied, timely LHS research to evaluate clinical or organizational practices to help systems modify, scale, or de-adopt changes in ways that maximize value within care delivery. A recent survey of health system leaders conducted by the National Academy of Medicine highlighted multiple benefits from this type of research, such as identifying questions that support the organization’s performance goals, using data to drive decision-making, improve patient care, and enhance the reputation of the system.

The problem. Health system leaders, practicing clinicians, and researchers often face barriers to engaging in learning health systems research, including lack of engagement between health care operations and research, shallow pools of expertise, a lack of pathways to identify and develop ideas, limited funding, and divergent goals or incentives. A 2015 National Academy of Medicine workshop noted that “…the pace of traditional research lags so far behind the real pace of change that results are outdated by the time studies are completed.”

The solution. In the 20 years since the publication of the Institute of Medicine’s report, Crossing the Quality Chasm, there has been an increasing emphasis on improving care delivery by ensuring that health care delivery research findings are quickly and safely implemented into clinical practice. The report describes how LHS can draw upon health care providers, payers, or policy systems “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” to achieve these goals.

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LHS researchers reside at the interface of research, informatics, and clinical operations within the walls of learning health systems. They need to form and lead multidisciplinary teams comprised of members from all levels of the organization, respond to patient needs and concerns, ascertain the priorities of health systems, encourage dialogue between research and practice, and increase the responsivity and applicability of research to the needs of practice without sacrificing scientific rigor or disrupting day-to-day clinical operations. This broad set of scientific and practical skills, when executed optimally, could remedy the disconnect between research and practice that is exacerbated by a fast-changing clinical context and limits on clinicians’ ability to engage in research.

However, embedded LHS researchers remain rare, in part due to the limitations of traditional research training programs. A program that is specifically designed to train embedded researchers who will focus on systematically generating, adopting, and applying evidence quickly to improve personalization, quality, equity, and outcomes of care is sorely needed.

The MN-LHS Mentored Career Development Program

The program. The MN-LHS is a three-year, funded LHS training vehicle for promising clinicians and researchers, supported by the collective strengths and expertise of its partner sites. The award from AHRQ and PCORI funds approximately three MN-LHS scholars each year and is open to clinicians who are dedicated to LHS research or seeking to pivot toward an LHS approach. The primary components of the program are individualized coursework indexed off AHRQ LHS Competencies and PCORI Methodology Standards, and an intensive mentored research experience embedded in an active health care system.

The partners. The University of Minnesota School of Public Health, Mayo Clinic, and Hennepin Healthcare form the core of the MN-LHS, supplying overall governance, individualized training experiences, and program evaluation and improvement. The program’s impact is amplified via a network of collaborating clinical partners who have agreed to formally participate in the work of the program. Each of the partners—Fairview Health Services, Minneapolis VA Health Care System, Children’s Minnesota, Ebenezer Senior Living, Essentia Health, and HealthPartners—are committed to assisting in the recruitment of scholars and mentors, supplying clinically-embedded experiential externship opportunities, and serving on the program’s governance structure. The majority of the health care delivery systems included in the MN-LHS have research shops that are already proximal or fully embedded in practice, thus facilitating research and educational experiences for scholars. The University of Minnesota Office of Academic Clinical Affairs and M Health Fairview recently joined the MN-LHS as a partner, supporting up to five scholars annually.

​LHS researchers reside at the interface of research, informatics, and clinical operations.

The plan. The specific goals of the MN-LHS Program are to 1) provide rigorous, competency-based training in the design and conduct of high quality LHS research, with standard and individualized components; 2) ensure MN-LHS scholars acquire embeddedness thinking and skills in LHS research, including practical questions around health equity, stakeholder engagement, and responsible conduct of research; 3) offer experiential learning opportunities and externships; and 4) leverage extensive multidisciplinary mentoring capacity to support scholar development as productive and embedded LHS investigators. These goals are accomplished through deployment of the following components:

1. Pre-award planning for each scholar to map their current competencies against the aforementioned AHRQ LHS Competencies, creating individual development plans to achieve greater LHS competency, and developing contracts between the scholars and their mentors.
2. Competency-based training at a fundamental level in the AHRQ LHS Competencies and PCORI Methodology Standards through a) required coursework; b) DesignShop, a biweekly MN-LHS forum spanning the three-year program; c) biannual MN-LHS retreats; and d) additional coursework at the University of Minnesota to ensure scholars achieve mastery in areas related to their research.
3. A research practicum for experiential learning embedded within clinical practice.
4. Strong program oversight and evaluation tailored to the program competencies and milestones that we expect each scholar to achieve.

​The scholars. The MN-LHS Program is open to individuals engaged in innovative work who are U.S. citizens or non-citizen nationals, or individuals lawfully admitted for permanent residence with an earned clinical or research doctorate (e.g., PhD, ScD, DrPH, MD, DO, DC, ND, DDS, DMD, DNS, DVM, OD, DPM, EngD, DPT, OTD, PharmD, DSW, PsyD, or equivalent doctoral degree) and hold a full-time appointment at his or her respective institution. Candidates must be able to commit a minimum of nine person-months (75% of full-time professional effort) conducting research career development activities associated with this award for a two- or three-year period.

• Other qualifications include having:
• Approximately 10+ publications or a plan to pivot into a new area of research requiring additional training;
• An intense interest in pursuing a career in research in LHS;
• Demonstrated dedicated research time and departmental support; and

• An identified mentor within the MN-LHS network who has relevant training and experience aligned with the scholar’s overall area of interest.

Other factors that will be taken into consideration include balancing the racial/ethnic, sexual, scientific, geographic, and patient population diversity of the scholar profiles.

The payoff. Through established partnerships and abundant success with past training experiences, the MN-LHS Program is poised to develop scholars who will be preeminent LHS researchers. The program attracts and selects the highest-quality scholars from among the deepest of talent pools and subjects them to an unparalleled and intensively mentored educational experience composed of appropriately phased coursework and experiential learning. The MN-LHS is designed to contribute significantly to the scientific development of scholars, including their embeddedness potential and success.

More information about the program and its application process can be found at https://tinyurl.com/mp-mn-lhs.

Timothy Beebe, PhD, is Mayo Professor and the Head of the Division of Health Policy and Management in the University of Minnesota School of Public Health. Dr. Beebe is also Co-Director of the Minnesota Learning Health System Mentored Career Development Program (MN-LHS).