Author + information
- aHarrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- bDivision of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- cDivision of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
- ↵∗Address for correspondence:
Dr. Ankur Kalra, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Medicine (Cardiology), Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, Ohio 44106.
Fellows-in-training (FITs) and early career professionals (ECPs) are currently practicing in a complex health care environment. Indeed, there are multiple foci of interaction in a 21st-century academic medical center (AMC) extending beyond the traditional commitment to the tripartite mission of patient care, education, and research (1). These include interactions with community medical practices, post-acute care facilities, health information technology vendors, research institutes and industry, and public health agencies (2). Therefore, it is imperative for ECPs to have an in-depth understanding of the complex interplay among the regulatory, political, and socioeconomic components of the health care systems in which they work. Moreover, with the advent of the learning health system (LHS), investing in formal training pathways that simultaneously develop leadership skills in patient safety, health care quality, and health informatics—the quintessential building blocks of an LHS—can be pivotal in helping FITs and ECPs carve a career path in academic cardiovascular medicine as a clinician-administrator or an LHS expert.
Attaining leadership skills in patient safety, health care quality, and health informatics is necessary for FITs and ECPs interested in transforming an AMC into an LHS. According to a recent American Heart Association scientific statement, the delivery of cardiovascular care is well suited to serve as a model for the LHS due to its interaction with multiple areas of health care delivery, including chronic disease diagnosis, treatment, and prevention (3). How can FITs and ECPs cultivate and harness these avant-garde skill sets while still being engaged in rigorous training programs and busy clinical practices? This paper delves into the concept of an LHS; provides curriculum insights into skill sets in patient safety, quality, and health informatics; and culminates with 3 illustrative examples of training programs at AMCs. Our objective is to provide a roadmap for other FITs and ECPs to emulate and pioneer LHS efforts in their respective institutions.
What Is an LHS?
According to the Institute of Medicine, an LHS: 1) generates and applies the best evidence for the collaborative health care choices of each patient and provider; 2) drives the process of discovery as a natural outgrowth of patient care; and 3) ensures innovation, quality, safety, and value in health care (4,5). Simply put, an LHS is a platform in which every patient’s experiences are available to learn from; best practice knowledge is embedded in clinical workflows at the point of care to support clinical decision-making; process improvement is continuously achieved through ongoing study with a focus on patient-centric outcomes; and a workforce culture and infrastructure exist to facilitate this process to happen safely and within the health care system’s economy of scale (6).
Significance of an LHS in cardiovascular medicine
An LHS enables the pursuit of best practices and safer health care at a lower cost through a continuous cycle of rigorous study, learning, and improvement. This is a paradigm shift from how evidence is currently generated and applied to patient care in cardiovascular medicine. The vast majority of evidence-based knowledge that is generated from expensive, large-scale, prospective, multicenter, randomized controlled trials currently ceases its flow toward the end of the “afferent loop” of a learning cycle, at a stage where interpreted results fail to get adopted into clinical practice (Figure 1, steps 1 to 3). In fact, it takes approximately 17 years for new knowledge to get translated into clinical practice in the United States (7). In an LHS, the “efferent loop” of the learning cycle is completed by delivery of tailored messages to providers, translating into timely and actionable items (Figure 1, steps 4 to 6). For example, an LHS can facilitate a cardiologist’s point-of-care decision-making on the prescription of oral anticoagulation for stroke prevention in atrial fibrillation by providing real-time insights on the number of strokes averted and additional occurrences of bleeding events following the implementation of a new policy for referring atrial fibrillation patients to an anticoagulation center (8). Furthermore, it can utilize that information to facilitate shared decision-making conversations with a specific patient in the clinic or at the bedside. It can also provide real-time information while evaluating patients in clinic; for example, predictive analytics in an LHS can provide likelihood estimates on patients filling their antihypertensive medication prescription (8).
Successful examples of LHS exist throughout the spectrum of cardiovascular care delivery in the United States. Leveraging its electronic health record as the main data source for constructing point-of-care clinical decision support algorithms and real-time patient risk calculators, the Veterans Administration Clinical Assessment Reporting and Tracking program in cardiac catheterization laboratories nationwide has been effective. Data entered at the point of care by the provider is used for real-time implementation of quality and safety initiatives (e.g., rapid review and adjudication of major complications by a national committee of interventional cardiologists) (9). Similarly, the American Heart Association and the American College of Cardiology have both demonstrated continued, longitudinal improvement in stroke, heart failure, and acute myocardial infarction care using clinical registries as the prime data source through the GWTG (Get With The Guidelines) Stroke and Heart Failure programs and the door-to-balloon initiatives (10–12). Finally, the Group Health Cooperative, a nonprofit integrated health care system in Washington State, has successfully employed 6 phases of a rapid LHS in its quality improvement initiatives: internal and external scans, intervention design, implementation, evaluation, iterative adjustment, and dissemination (13). These examples illustrate the growing evidence base supporting that LHS improves patient outcomes and deliver high-value care (14).
Essential Skill sets for Becoming an LHS Expert
The essential skill sets needed to develop into an LHS expert include proficiencies within the domains of patient safety, health care quality, health informatics, and leadership. Although each of these is a distinct discipline, an LHS expert must synthesize working knowledge of relevant content from each of these fields that aids in promoting an LHS platform. Table 1 lists some of the relevant topics from each discipline that may be essential for development into an effective LHS consultant/expert (15).
LHS Champion: A Novel Career Pathway in Academic Cardiovascular Medicine
Innovation is needed to curtail health care spending, augment the delivery of value-based services, and improve the timely dissemination and implementation of evidence-based medicine (2). In response to this unmet need, several AMCs and cardiovascular medicine divisions have established centers of innovation; consequently, several training programs have emerged to foster professional development in this space. The 1-year certificate program at Harvard Medical School is one such example and focuses on peer collaboration, providing the nuts and bolts for delivering safe, efficient, cost-conscious, and high-value care with high-quality outcomes (15). Participation by busy FITs and ECPs is feasible, as coursework mostly consists of live interactive webinars and pre-recorded lectures. There are 3 in-person workshops per year, with continued access to faculty and mentorship, which is important in helping participants mature into “change agents” of the future.
Additional nondegree certificate programs as well as degree-granting programs have been developed at several institutions, including the University of Pennsylvania Health System and University of Michigan. At the University of Pennsylvania Health System, cardiovascular medicine fellows have the option of pursuing either a 12-month certificate program or a 24-month fellowship program in health care improvement and patient safety. The certificate program allows fellows to enroll in courses in quality improvement methods/patient safety while simultaneously becoming embedded in a local unit-based quality improvement team led by physician/nurse dyads. Ultimately, trainees complete capstone projects, present them at regional and national meetings, and join a local community of fellows committed to developing an LHS. Trainees completing the 24-month fellowship participate in the previously listed activities and earn a master’s degree while taking additional courses in topics such as quality metric development and implementation science. A strong, experienced, and committed multidisciplinary, multi-institutional team of mentors joins these 2 programs.
Similarly, at the University of Michigan, the Healthcare Administration Scholars Program provides a 20-month certificate program. Didactic lectures examine a gamut of topics ranging from health care economics, health care law and regulation, and operations management to quality and safety in health care, interprofessional education, health care information systems, and advocacy. Scholars also complete and present a mentored capstone project at the conclusion of the program, highlighting the principles and skills of quality improvement and health care administration acquired during the project experience. These opportunities enhance experiential learning and provide trainees a foundation upon which to build their skill set in LHS.
With health care reforms such as the Medicare Access and CHIP Reauthorization Act, Merit-based Incentive Payment Systems, and Advanced Alternative Payment Models becoming integral parts of the medical lexicon in the current health care environment, it is imperative for the current generation of FITs and ECPs to learn the concepts underpinning LHS and to help catalyze the transformation of AMCs into LHS. Perhaps LHSs will help AMCs realize their potential of point-of-care, individualized, and personalized health care delivery.
- James E. Tcheng, MD ()
RESPONSE: Enabling the Learning Health System, One FIT at a Time
“I skate to where the puck is going to be, not where it has been.”
—Wayne Gretzky (1)
Health care is undergoing a dramatic transformation from a largely reactionary, transaction-oriented, volume-based payment model to the promising paradigm of data-driven evidence-based care, pay for performance, and population health management. Even with the uncertainties about the velocity and execution of this transformation, certain foundational competencies will become increasingly relevant enablers of the learning health system (LHS) (2). The excellent discussion by Kalra and colleagues articulates a key aspect of what is needed to accomplish that vision, namely, the expansion of medical training in the dimensions of patient safety, health care quality, clinical informatics, and leadership.
The requisite building blocks are actually not new. Among the 6 Accreditation Council for Graduate Medical Education core competencies, systems-based practice and practice-based learning square particularly well with the LHS framework. The American Board of Medical Specialties (the parent organization responsible for board certification and maintenance of certification programs) emphasizes ongoing assessment and improvement in the quality of care at both the individual patient and health care system levels. The American Medical Informatics Association (AMIA) has existed for >35 years, and was itself formed by the merger of other organizations focused on informatics (the science of data) and information technologies. It is the elevation and alignment of these somewhat marginalized dimensions of health care into a composite whole that is now being recognized as key to delivering the promises of an LHS.
How should the challenge be answered? Although Kalra and colleagues identify several formal programs for developing the “LHS champion,” should we not instead be calling for “LHS everywhere?” The hallmark of LHS is continuity between evidence generation, clinical application, and assessment built on a data framework. Key commitments are needed across both academia and nonacademic settings to achieve this construct. To cultivate a base level of competency in the dimensions of patient safety, clinical quality, informatics, and leadership, the core curriculum of cardiology fellowship (and perhaps even residency) should be expanded to include introductory-level training in these topics. At the practical level, obvious opportunities to evaluate data informing the quality of care should be routinely identified. For example, we annually assign our fellows-in-training (FITs) a quality improvement project based on a systems-based issue identified in our morbidity and mortality conferences. The nationally developed AMIA 10 × 10 program (3) is a resource calibrated to providing a foundational command of data science. Beyond training programs, our profession—whether early, middle, or late career—must recognize and embrace the growing role of data in clinical practice. We should pressure colleagues, administrators, and health information technology vendors for effective and high-usability structured reporting—the capture of reasonably complete, high-quality data integrated into processes of care (4). This paradigm shift, moving away from analog (text) to data-rich documentation, is a requisite transformation if the LHS is to be realized. Finally, the energy for the transformation must be shared—and better yet driven—by FITs and early career professionals focused on a commitment to clinical excellence based upon data. Supplementing traditional methods of scientific discovery by expanding knowledge while improving care through the LHS paradigm must be enabled and embraced by the entirety of the health care enterprise.
- ↵BrainyQuote. Wayne Gretzky. Available at: https://www.brainyquote.com/quotes/quotes/w/waynegretz383282.html. Accessed September 27, 2017.
- Krumholz H.M.
- ↵American Medical Informatics Association. AMIA 10×10 courses: training health care professionals to serve as informatics leaders. Available at: https://www.amia.org/education/10x10-courses. Accessed September 17, 2017.
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The authors thank Dr. Charles P. Friedman for his input on this manuscript. Dr. Friedman is Chair of the Department of Learning Health Sciences at the University of Michigan Medical School, codirector of the Safety, Quality, Informatics, and Leadership certification program at Harvard Medical School, and former Deputy National Coordinator at the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services. Dr. Friedman first explored the concept of Learning Health Systems in 2010 through the Institute of Medicine while at the Office of the National Coordinator for Health Information Technology.
Dr. Sinha is a section editor of the Fellows-in-Training and Early Career Page of the Journal. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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