... Use of Learning Health Care Systems to Improve Care for Traumatic Brain Injury...

... Payment models can be used as mechanisms to foster positive patient outcomes by increasing care affordability, coordination, and access. (Davidson)...

... Sociotechnical infrastructure enables each clinical department or unit to function as a learning health system (LHS), which can then aggregate to a collective LHS at the larger organizational level. (Lomotan)...

... Feedback loops foster the development of knowledge and situational awareness within a health system. Building feedback loops, capturing higher-quality data, and conducting randomized trials are LHS ...

... The Department of Veterans Affairs strives to offer integrated, individualized, and interdisciplinary delivery of quality, long-term TBI care that maximizes patient outcomes. Data collection and analysis of outcome comparisons inform ...

... 1 This list reflects the rapporteurs’ summary of points made by the identified speakers, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect ...

... The Center for Medicare and Medicaid Innovation is building feedback loops with providers, patients, and patient organizations to better understand patient needs and establish incentives to encourage practices that meet those needs. (Davidson)...

... Organizations should strive to collect findable, accessible, interoperable, reusable, and computable data that enable learning transfer. (Lomotan)...

... Approaches that can help rural or less well-resourced systems develop and participate in learning health systems include providing financial or payment system incentives, incorporating virtual care options, and making use ... strategies such as simple randomization to test and learn from different practices. (Davidson, Horwitz, Lomotan, Scholten)...

... health systems (LHSs) can address unmet priorities that apply to traumatic brain injury (TBI). The session discussed the Centers for Medicare and Medicaid Services (CMS) Innovation Center’s role in testing, learning, and scaling approaches for more effective care delivery and payment; the ... and analytic infrastructure needed to develop and maintain LHSs, examples of operationalizing LHS principles at New York University (NYU) Langone Health, and how the Department of Veterans Affairs ... the concept of an LHS for veterans with TBI. Participants explored the use of such systems to identify gaps, barriers, and strategies to effectively address institutional needs, including how their organizations use data and innovation to improve health care delivery. ... Goldstein, senior advisor at the Department of Health and Human Services, moderated the session....

... Center for Medicare and Medicaid Innovation...

... Kathryn Davidson, director of the learning and diffusion group at the Center for Medicare and Medicaid Innovation (CMMI), described the development of payment models to support patient outcomes. A licensed clinical social worker, she began her ... overseeing randomized clinical trials in community settings. At this intersection of behavioral health, social services, and primary care, she witnessed the profound effect of loss of grant funding on outcomes. Her work at CMMI enables her to direct her implementation ...

... patient outcomes and feature flexibilities that engage patients and caregivers. Born from the 2010 Affordable Care Act, CMMI tests new payment models that aim to reduce health care costs and increase quality. The ... works to improve patient outcomes by narrowing quality measures and by identifying incentives and flexibilities that promote innovation at the point of care delivery. Noting the high threshold of simultaneously reducing cost and improving quality, ... that CMMI has tested approximately 50 models, but only 4 have been scaled to date. Innovation in care delivery is not limited to tested models, and CMMI’s learning and diffusion group and evaluation teams work to examine, understand, and enable innovative practices that benefit patients. As ... develop practices that increase the patient experience of affordability, coordination, and access, CMMI considers the payment models needed to encourage these practices....

... Agency for Healthcare Research and Quality...

... Edwin Lomotan, senior advisor for clinical informatics in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality (AHRQ), discussed his organization’s role in providing tools, resources, and funding to support the development of LHSs. The agency’s ... is to produce evidence to improve the safety, quality, accessibility, equity, and affordability of health care, as well as ensuring the use of evidence in the field. For example, the AHRQ Evidence-Based Practice Center program ... a series of evidence reports on LHSs featuring topics such as engaging patients, families, and caregivers and addressing diagnostic errors. The agency’s activities to support patient-centered outcomes research include training LHS researchers. The program ... Lomotan leads focuses on advancing patient-centered clinical decision support, which is relevant to LHSs and incorporating perspectives from patients, families, and caregivers. In addition, he is currently among a group convened by the University of Michigan ... that identifies the stages of a health care system transitioning to becoming an LHS. Sociotechnical infrastructure provides the personnel, processes, and technologies needed to create a system in which each unit of a health system—such as a TBI care center—functions as a small-scale LHS. These ... can then collectively operate as an LHS at the organizational level, which incorporates and expands learnings across the organization and creates a whole greater than the sums of its parts....

... Leora Horwitz, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Health, explored strategies to shift health...

... systems toward becoming LHSs. The complexity of health care systems poses challenges to understanding how all parts operate. Feedback loops are a mechanism for developing knowledge and situational awareness about the health system. An effort to ... . Each September, NYU Langone Health activates an electronic alert instructing nurses to administer flu shots to patients. Several years ago, Horwitz and colleagues realized that the flu shot alert was initiated 22 times per patient per day, and was ignored 99.5 percent of the time, even though it ... of varied feedback. This feedback loop revealed that the alert was issued within operating rooms (ORs), postanesthesia care units, endoscopy suites, and other locations where flu shots are not administered. The team then recognized that the information technology (IT) department set the alert to ... four to six times a day in many parts of the hospital, update rates within the OR are sometimes as frequent as once per minute. Despite the long-standing frustration that incessant flu shot alerts caused OR nurses, a mechanism for them to communicate this to IT was lacking. Once Horwitz’s team ... feedback is a primary strategy in creating an LHS. For example, feedback loops could inform staff in medical offices that the television volume and lighting brightness are causing discomfort for their TBI patients....

... strategy to employ in shifting systems toward becoming LHSs, said Horwitz. Although data are plentiful in health systems, the ability to collect and convert meaningful data into knowledge is often limited. Health systems typically gather data points rather than use a structured approach that ... synthesis, judgment, experience, trajectory, and thought processes. She offered the example of a project several years ago aimed at optimizing testing in the emergency department (ED) for pulmonary ... blood clots in the lungs. These clots can be catastrophic, yet they are easy to miss. Testing involves a computed tomography (CT) scan with radiation and contrast; therefore, it is not feasible or advisable to administer to all patients in the ED. Horwitz’s team built an automatic PE risk score ...

... of NYU’s proximity to John F. Kennedy International Airport, the hospital frequently treats patients who have traveled on long overseas flights and have blood clots in their legs; however, the scoring system does not account for the PE risk that travel poses. Some doctors cited patients with ...

... much higher. The center used this knowledge in reeducating doctors regarding their intuition, encouraging them to trust their judgment in some cases and advising them against overweighing certain factors that did not significantly increase the risk for PE. Horwitz stated that a TBI LHS could solicit ... from providers about whether they suspect a patient has a TBI, the predicted trajectory, and treatments they predict as likely to be effective. A feedback loop could collect and analyze such data to inform TBI care....

... The ability to generate readily and rigorously evaluable data is not reliant on receiving large grants, said Horwitz, noting that her team at NYU Langone Health has conducted ... 30 randomized trials in the absence of funding from the National Institutes of Health. One such trial arose in response to the substantial decline in ... vaccination rates during the COVID-19 pandemic. Her team solicited feedback from parents of pediatric patients in order to target text message reminders. Parents offered reasons for delayed ... that included fear of contracting COVID-19 while in the clinic, the time commitment required to attend appointments, and a lack of understanding the rationale for vaccination. The team created several reminder messages with varied content and randomized delivery of the text messages to ...

... Again reaching out for feedback, the team called parents to ask whether they had received the text messages and why they had not acted on them. Most of the parents indicated the lack of follow through was attributable to receiving the reminders while they were ... work or when the clinic was closed, rendering them unable to call and make the appointment. The team conducted an additional randomized trial in which one group of parents received an initial text message in the evening that included a link to online appointment scheduling and a ...

... tripled in comparison to the control group not receiving a reminder. After randomized trials revealed the role of staggered text reminders in increasing vaccination, the practice was adopted systemwide. The LHS strategies of ... feedback loops, capturing higher-quality data, and conducting randomized trials help illustrate opportunities applicable to advancing learning systems for TBI care....

..., only 10 percent of VA locations include onsite specialized, interdisciplinary TBI care. Drawing from their experience working with both TBI teams and individual veterans, case managers provide highly valued input. Using the electronic health record (EHR), VA created a plan of care templated note ... is easily searchable and can be updated as a patient progresses through a treatment plan and transitions to a wellness plan. VA’s mission of helping veterans access lifelong care and wellness underlies a shift from episodic care to long- ... of Rehabilitation Facilities. Extensive VA research efforts—such as long-term implementation studies, partnerships with academic institutions, and collaboration with 16 TBI model systems nationwide—have generated a longitudinal database. Outcome comparisons from these data foster an ...

... that provides stipends to reimburse some of the time caregivers dedicate to care. Other VA benefits include home modification, vehicle adaptation, and housing support for homeless veterans. Implementing a whole health model of care, VA is working to shift from a focus on what is the matter with a ... to what matters to the veteran. This priority seeks to offer integrated, individualized care delivery that maximizes patient engagement and treatment outcomes for veterans....

... Data Strategies to Develop Learning Health Systems...

... Goldstein asked how organizations can move an LHS forward strategically and innovatively while integrating considerations such as program evaluation and stakeholder engagement. Davidson noted CMMI efforts to foster patient- ... and value-based care in the context of the large...

... Centers for Medicare and Medicaid Services (CMS) system, and that these strategies align well with LHS core principles. For example, efforts often seek to create flexibility, use data-driven decision making, ... patients, and make use of cohesive payment models to defragment care delivery and improve outcomes. Lessons from such models can inform other organizations’ LHS efforts....

... example, the Medicare skilled nursing facility 3-day inpatient hospital stay waiver was coded with different names in various models. The learning and diffusion group has been systematically identifying such data entry issues to generate consistency and simplify data collection and analysis. Using ... from claims, quality measures, learning systems, and evaluations, the group draws conclusions that inform future model development....

... from care delivery experts about practices that improve patient outcomes. To that end, CMMI is building feedback loops with providers, patients, and patient organizations to better understand what patients need and, in turn, establish incentives to shift practice toward meeting those needs. ...

... process of becoming an LHS. Lomotan noted the relevance of a maturity model in considering an organization’s starting point from which to compare and track improvement, and stated that data infrastructure strategies will vary between care systems. Data should capture unmet patient needs and ... that are working, he said. Furthermore, organizations should strive to collect data that are findable, accessible, interoperable, reusable, and computable. Various mechanisms for collecting such data include decision logs, use spreadsheets, and systems based on artificial intelligence (AI). ... a focus on applying what has been learned across settings and contexts, AHRQ works to analyze data from multiple agencies and has recently developed an application programming interface that indexes repositories and creates interoperable data points that can be used ...

... Data and Continuous Improvement...

... Regarding the creation of a learning system that incorporates up-to-date evidence and establishes a culture of continuous quality improvement, Horwitz emphasized the importance of collaboration with departments and disciplines within a ...

... care in need of support. Rather than dictating changes, she and her team ask providers about pain points patients are experiencing, practices that seem to work but are lacking data, and facets of the program that ... the time, data on untested practices do not reflect the benefit that providers ascribe to them. These cases are viewed as opportunities for iteration and improvement. For example, the team spent 6 years tweaking the flu vaccine computer alert to achieve a rate of less than one alert per patient per day. ... The learning process requires time and experimentation, she emphasized, and once a better method is identified, NYU Langone Health generalizes it to routine practice across appropriate departments....

... Competing priorities are inherent in a system as large as VA, and data can serve as leverage for assets and resources, said Scholten. In an effort to prioritize TBI needs within the entire VA health system, he works to integrate TBI with other agency-wide ... the 1,000 points of care delivery within the VA system, medical records can span numerous care locations. VA will soon introduce a new EHR system, and integration of all existing medical records could require a 10-year time frame. Meanwhile, investment in data and programming requests for the ... EHR will be limited. Furthermore, 75 percent of post-9/11 veterans with TBI also have post-traumatic stress disorder and receive care from mental health partners. This holistic model of care increases the complexity of integrating all medical records....

... Comprehensive data enable dashboard metrics that aid in identifying frequency of quality-of-care outliers and can be used in improving the practice of individual providers. Over time, the use of data shifts the culture toward evidence-based care, he said. ... VA case management uses data to annually identify TBI patients with chronic disability; case managers then follow up with veterans and update wellness plans accordingly. After 2 years of establishing this process, the percentage of veterans with TBI that receive annual, in-person ... health providers has increased from 20 percent to 50 percent. Goldstein remarked on the interplay of care delivery, organizational structure, data, and technology. As a result, he reflected, consideration should be given to the timing of engaging stakeholders in public and private partnerships to ...

... Joseph Giacino, director of rehabilitation neuropsychology at Spaulding Rehabilitation Hospital and professor of physical medicine and reha-...

... bilitation at Harvard Medical School, asked about the operational structure of NYU Langone Health’s evidence-to-practice feedback cycle. Horwitz replied that the Center for Healthcare ...

... of California, San Diego, asked about mechanisms such as incentives to translate knowledge gained across systems, including those in rural areas, and support the ability of less well-resourced systems to implement LHS practices. Scholten replied that VA uses virtual care in helping address inequity ... the geographical availability of TBI care centers and that the federal nature of VA enables nationwide use of virtual care, regardless of state boundaries. Davidson noted that CMMI recently analyzed ... of value-based care to identify types of providers and geographical areas that these models have not yet reached. To address identified gaps and bolster primary care, CMMI is testing models that feature upfront infrastructure, streamlined models and simplified incentives to support more ... participation in value-based care in alignment with LHS goals. She noted the Making Care Primary model and States Advancing All-Payer Health Equity Approaches and Development (AHEAD) model, aimed at fostering coordinated, high-quality, and cost efficient ... across primary and specialty disciples to improve health outcomes....

... Lomotan echoed the importance of addressing health inequities in the design stage of an LHS, which needs to incorporate feedback from patients and families in order to build patient-engaged systems that address barriers to care. He emphasized that too often, patient input is not solicited until ...

... Horwitz commented that although advanced EHR randomization and AI models can be used to analyze and learn from system data, NYU also uses simple strategies to align practice with LHS principles, and that these strategies can be employed by many ... of care systems. For example, a project conducted with a call center alternated between two scripts on a weekly basis and filtered call lists according to medical record numbers being odd or even. These simple methods are not formal randomized trials but can be used to ...