Concurrent session I: Conceptual frameworks for learning health systems

Thursday, March 8, 1:30 – 2:30 pm
Salon D
Chair: Jason Sutherland, UBC Centre for Health Services and Policy Research

An evolving framework for learning health ecosystems in Canada

Presenting author: Marc-Andre Blanchette, Institut national d’excellence en santé et en services sociaux

Co-authors: Matthew Menear, Olivier Demers-Payette, Khalil Moqadem, Denis Roy

Objective: The notion of ‘Learning Healthcare Systems’ (LHSs) emerged over a decade ago in the US but only recently has begun to gain traction in Canada. Despite its growing popularity, relatively few healthcare systems in the US or elsewhere have aligned their structures and services to the LHS vision and there remains much conceptual confusion as to its defining elements. Given important differences in healthcare practice and policy in the US compared with Canada, we wondered whether the LHS concept was relevant and adaptable to Canadian healthcare contexts. Our objective was thus to identify the key elements of the LHS concept and to develop an integrated framework that could be used to guide potential system transformations in Canada.

Methods: We performed a narrative literature review that included structured searches for conceptual and empirical reports on the LHS, conducted in Pubmed, Embase, the Cochrane Library, and the grey literature. These searches yielded over 30 relevant articles and reports, which were analyzed and discussed during several meetings of an interdisciplinary team of fellows at the Institut national d’excellence en santé et en service sociaux (INESSS). During the framework building process we also drew from several theories from different disciplines, including organizational and educational sciences.

Results: Our resulting LHS framework comprises four main elements: 1) LHS Enablers, 2) LHS Processes, 3) LHS Outcomes, and 4) Core values of the LHS. Enablers refer to the various systems, structures and resources that provide the foundation for a learning healthcare ecosystem. We identified five main enablers (scientific, social, technological, political and ethical) that can be aligned to support LHS processes, including the continuous cycle of learning and action. This cycle depends on processes such as collaborative sensemaking and reflective practice, as well as knowledge management and mobilization processes to convert data into usable, contextualized knowledge. The LHS produces a range of outcomes, but strives to maximize patient experiences, population health, and healthcare costs. Core values (e.g. transparency, equity, shared accountability) underpin the entire LHS.

Conclusion: This framework is evolving but has potential as a useful framework for understanding the LHS concept in Canadian contexts.

Bringing the learning healthcare system principles home: Acknowledging and enhancing learning in the midst of everyday practice

Presenting author: Martha MacLeod, University of Northern British Columbia

Co-authors: Dave Snadden, Cathy Ulrich

Current conceptualizations of learning healthcare systems promote the integration of research and practice through the reciprocal generation and application of evidence for rapid, point-of-care improvements. It is contended that through the process of identifying problems and implementing innovative solutions informed by advanced analytics of readily available data, the healthcare system can be continually improved to better address the needs of patients. Accordingly, much of the current focus is on integrating research into routine care delivery at the level of data systems and organizational structure. Such a focus on research and the use of data at the systems level is underpinned by a number of assumptions about the capacity of healthcare systems and the ways in which people in the organization, that is, individuals and small groups, incorporate evidence at the point of care and throughout the system.

This presentation will examine underlying assumptions about knowledge, learning, research, and healthcare organizations that are at play within current approaches to learning healthcare systems. The argument is made that in order to actually foster a learning healthcare system it is not enough to focus on linear conceptions of implementation and research that primarily focuses on identifying and addressing problems and gaps at a systems level. Needed is a more detailed, nuanced understanding of how actors in a healthcare system are actually learning in everyday practice and how processes of implementing change really happen. This alternative, but complementary approach, based in philosophical hermeneutics, will explore how practitioners and others learn in the midst of everyday practice and how organizations support or hinder that learning. The critical interplay of context, practice, relationships, learning, and change will be highlighted. The discussion will be illustrated by examples from research in rural and northern settings, and the presentation will conclude with an invitation to reflect on how alternative ways of understanding context, knowledge, learning, and practice can be incorporated into implementing change to better address the needs of patients and create a responsive healthcare system.

Using the RE-AIM framework to evaluate a specialized medical-dental clinic for adults with developmental disabilities

Presenting author: Jonathan K.Y. Lai, McGill University and Centre for Innovation in Autism and Intellectual Disabilities

Co-authors: Malvina Klag, Keiko Shikako-Thomas

The public health care system in Canada relies on public-private partnerships to complement and improve quality of care. In Quebec, adults with developmental disabilities experience significant gaps accessing health services after leaving pediatric care. As such, the Centre for Innovation in Autism and Intellectual Disabilities, supported by the Miriam Foundation, founded a specialized interdisciplinary medical-dental clinic for adults with developmental disabilities. The goal of the clinic is to optimize care for this population by creating a sustainable and replicable service model. The Centre has committed to implementing a program evaluation as part of collaborative efforts to create a learning health care system for individuals with developmental disabilities in Quebec. This presentation will introduce a comprehensive evaluation framework based on the RE-AIM framework for a specialized medical-dental community clinic serving adults with developmental disabilities.

Using a Participatory Action-oriented approach made possible through the CIHR Health Systems Impact Fellowship, researchers and stakeholders at the Centre co-designed an evaluation that aimed at: 1) enabling replication of the service model and 2) catalyzing public health system action. The context was established by meetings with leaders in the organization and documentation analysis. Individual interviews with the management team and clinicians were carried to understand the current process and challenges. Leaders of other Canadian organizations serving this population were interviewed to gain insight into their program evaluation development and pertinent documents were analyzed. After a literature review of evaluation tools, the RE-AIM framework (Glasgow et al., 1999) was adapted for use, consisting of 5 axes: Reach, Efficacy, Adoption, Implementation, and Maintenance. Domains were conceptualized under each axis to allow for continual improvement and for tracking system change. Measurement tools under each domain were chosen through discussions with international experts.

The framework creates an important blueprint for a program evaluation and the creation of a Learning Health Care System within this organization, with potential extensions to the public system through a structured understanding of public-private partnerships. This evaluation will provide insights into the process of integrating care for a marginalized population with chronic conditions in the public health system.

Using the learning health system framework to develop strategy for improving management of the elderly frail and patients with palliative needs

Presenting author: Ivy Cheng, Sunnybrook Health Sciences Center

Co-authors: Andy Smith, Ross Baker

Background: The majority of patients with palliative care needs prefer to have end-of-life care at home. However, greater two-thirds of patients die in hospital.

Objective: To use a learning health system framework for strategy to improve management of the elderly frail and patients with palliative needs.

Methods: Health Care Reform and Patient’s First Legislation in Ontario have developed a framework for Learning Health System Model. Sunnybrook Health Sciences Center is the Hospital Resource partner in the North Toronto sub-region of the city’s Central Local Health Integrated Network. Using core competencies, such as data analytics, networking, leadership, collaboration, project management, program evaluation, change management and reflective practice, we aim to improve our North Toronto sub-region’s health care model for the elderly frail and patients with palliative needs.

Results: Data analytics of our hospital’s administrative database for high frequency emergency department users or prolonged emergency department length-of-stay is an initial method of identifying the elderly frail and patients with palliative needs cohort. Data provides evidence of service gaps. Merging this the data with pre-existing models (Better Care and Health Links) provides an electronic platform for improved management. Collaboration and networking within and outside the hospital are necessary to transition concept to reality. Continual evaluation of the processes through data analytics are embedded in the framework. Engaged leadership and patient engagement are key success factors in this process. This framework with associated challenges will be presented.

Conclusion: The Learning Health System Framework is an appropriate model for achieving the goals of improving health care for patients with palliative needs and elderly frail.