Digital Infrastructure for the Learning Health System The Foundation for Continuous Improvement in Health and Health Care: Workshop Series Summary (2011) / Chapter Skim
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2 Visioning Perspectives on the Digital Health Utility
2 Visioning Perspectives on the Digital Health Utility
Pages 71-98
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From page 71... ...
The included manuscripts explore the current state of the digital infrastructure from their corresponding perspective, articulate their views of the potential for a learning health system supported by an integrated digital infrastructure, and identify sector-specific needs and priorities for progress. Adam Clark, formerly of the Lance Armstrong Foundation (now FasterCures)
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From page 72... ...
She states that increases in safety, quality, and effectiveness of health care will require investments in a digital infrastructure capable of collecting information across the longitudinal "patient-focused episode," and feeding back performance results along with clinical decision support for patients and clinicians.
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From page 73... ...
The principal challenge, they note, is the lack of an integrated, modernized digital health infrastructure that is used by a trained workforce and stewarded by public health leaders who understand the potential benefits for population health. Accordingly, they articulate the need for a more unified vision of a digital infrastructure for population health, including development of a population health approach to data standards; aggregation and infrastructure; and intelligent, bidirectional messaging for patients and consumers.
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From page 74... ...
Individual interfaces to personal health records will would provide resources for individual health management, and could provide individuals with the control to donate and distribute their medical information as they see fit. Individuals as Consumers of Health Information The goal of patient-centered health care is to allow patients to play an active role in their healthcare decision making by working with healthcare providers to identify tools and knowledge appropriate for their health.
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From page 75... ...
A learning health system should account for this context, driving semantic content and resources useful to the individual. By linking patients' health information with an integrated electronic health information exchange, a knowledge environment can be built to connect clinical care, research, policy, and coverage that supports the best application of medical technologies for an individual patient's needs.
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From page 76... ...
A LIVESTRONG survey2 conducted in the spring of 2010 on electronic health information exchange discovered overwhelming support among the respondents for using electronic exchange to supply personal health information to providers as well as share clinically annotated information from their health records with researchers (Table 2-1)
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From page 77... ...
In this same time frame, genetic technologies should have advanced to allow individual genome sequencing as a standard clinical analysis. The combination of these approaches will change our approach to diagnosing and treating complex diseases like cancer, drive molecularly informed comparative effectiveness research, aid in developing targeted treatments and personalized medicine, and improve care through federated health information exchanges.
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From page 78... ...
This decision support will be developed through a learning system composed of multiple feedforward and feedback loops, connecting the relevant members of the healthcare team. When we execute this it will lead to marked improvement in population health; at least 100% improvement in delivery of patient-approved, evidence-based care; and at least a 30% reduction in the cost of evidence-based health care delivered (I am not promising decreased overall healthcare costs)
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From page 79... ...
In the case of questions impacting population health, agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration (FDA) are the logical actors to define the questions and commission user-centered development of the electronic tools that will make data collection efficient enough to be used in everyday care.
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From page 80... ...
Finally, existing HIT systems need fundamental redesign to integrate feed-forward and feedback information loops into usable care processes. This is unsurprising, considering how preliminary our understanding of care processes and their information needs still is, but adds significant costs to process redesign and management.
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From page 81... ...
Corrigan, Ph.D., M.B.A. National Quality Forum It has been 10 years since the Institute of Medicine issued its landmark reports, To Err Is Human and Crossing the Quality Chasm, focusing national attention on the need to improve health care quality and safety (IOM, 2000, 2001)
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From page 82... ...
A digital infrastructure that can support robust performance measurement and improvement systems is a necessary prerequisite to succeed in this new environment. Framework for Performance Measurement A two-dimensional framework is guiding the development of performance measures and performance measurement requirements for public reporting and value-based purchasing: Crosscutting areas: The National Priorities Partnership convened • by NQF has identified six crosscutting areas that impact most if not all persons/patients, including population health, safety, care coor dination, patient/family engagement, palliative care, and overuse (National Priorities Partnership, 2008)
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From page 83... ...
. To assess whether the health system is taking appropriate steps to prevent AMIs, information must be captured on the health status and risk behaviors of the entire population and the services provided to mitigate risk (e.g., programs to lower cholesterol levels through diet, exercise, and medication)
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From page 84... ...
Population Health Palliative/End of Life Care Overuse Episode begins–onset of Episode ends –1 symptoms year post AMI Safety FIGURE 2-2 Two-dimensional measurement framework applied to acute myocardial infarction. Figure 2-2.eps Implications for the Digital Infrastructure A patient-centered approach to designing the digital infrastructure will be needed to support quality measurement and improvement.
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From page 85... ...
Achieving the best outcomes for patients and populations requires the ability to capture information from, and enable communication with, all residents of a community regardless of whether they use healthcare services. It will also be important to capture "context information," such as race, ethnicity, language, socioeconomic status, and employment, all of which influence adherence to treatment plans and patient outcomes, and are needed to inform policy.
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From page 86... ...
Comparisons among strata are computed, often involving sophisticated numerical or machine learning methods, and inferences made with respect to quality of care, technology assessment, best evidence discovery, or comparative effectiveness. Thus, most of our science associated with care improvement is inexorably linked to information processes.
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From page 87... ...
The duality of biology and medicine having become information-intensive domains, coupled with our vast capacities to manage and manipulate information, make it inevitable that a similar "commons" of biomedical information will form a hub from and to which investigators and practitioners will draw and contribute. A foreshadowing of this reality is already evident in the genomic community, with the myriad of publicly accessible databases that surround the original Genbank suite of resources.
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From page 88... ...
While presently many obstacles -- including privacy, confidentiality, and intellectual property concerns -- make this vision impractical, one critical path issue remains the reality. Most health information is neither comparable nor consistent among providers, record systems, or researchers.
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From page 89... ...
Beginning with the Health Information Standards Planning Panel in the early 1990s, and moving through the American National Standards Institute's Healthcare Informatics Standards Board, the Health Information Portability and Accountability Act, the Healthcare Information Technology Standards Panel, and the Office of the National Coordinator for HIT (ONC) HIT Standards Committee, there have been significant resources expended on this problem.
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From page 90... ...
A digital infrastructure for the learning health system can offer immense opportunities for population health improvement in public health surveillance and response, population-based research and policy, coordination and quality improvement, and health education and communication. Challenges to achieving this vision include a lack of a sound electronic public health infrastructure, the need to advance workforce skills, polices that force categorical use of funds and short budget cycles, and uneven understanding among programmatic leaders about public health benefits of HIT.
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From page 91... ...
The digital infrastructure for the learning health system can offer immense opportunities for population health improvement and, more importantly, can serve as a conduit for bringing the domains of population health together. Table 2-2 identifies five areas of population health services and TABLE 2-2 Types of Population Health Activities and Opportunities for Provider Engagement Population Health Area Opportunity for Provider Engagement Surveillance and response Identify sentinel events, emerging illness, and injury trends.
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From page 92... ...
Given the challenges described above, the capacity and capability of public health information systems need to be modernized. Box 2-2 identifies some of the benefits of an integrated, modernized electronic infrastructure that enables secure, authorized bidirectional communications with governmental public health agencies and other organizations providing population health services.
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From page 93... ...
• an provide "evidenced-based practice" as well as "practice-based evidence" C • ollaborative efforts to implement clinical decision support systems C • eadership on efforts to measure and monitor the health of the community by L applying data analysis competence • apability to execute large population health/community-level changes through C recommendations, guidelines, and public policies • bility to translate impact of interventions to public health problems A • ptimize systems for disease surveillance, analysis, and alerting O • oordinate efforts to implement clinical decision support systems that better C integrate decision support across multiple diseases/conditions to improve disease management Benefits to public health • bility to use outcomes data from electronic health records and other HIT to A supplement existing surveillance methodologies and information • bility to optimize systems for disease surveillance, analysis, and alerting A based on lessons learned • ain new knowledge to improve care coordination and outcomes, especially G for chronic diseases • uicker translation of insights gained from clinical environment to potential Q interventions to possible public health recommendations • oordination of services and research with academic and learning community C • reation of a framework where the trend of new and existing acute and chronic C conditions are correlated with select population-level metrics (e.g., demo graphics, socioeconomic status, prevalence of other comorbidities, community characteristics) SOURCE: Adapted from Improving Population Health and the Minnesota e-Health Initiative fact sheet.
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From page 94... ...
various surveys and other sources Figure 2-3.eps FIGURE 2-3 Minnesota example of public health infrastructure relative to other systems. Recommendations Establish a shared vision and action plan for population health and a clear path to success.
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From page 95... ...
Adopt specific approaches to data standards, aggregation, and/or infrastructure that will help achieve better population health outcomes • Improve federal and state leadership and coordination on identifi cation and use of standards for interoperability including technical, semantic, and process interoperability. • Establish the framework for tools that can present population health data in ways that can profile the health status and disease burdens of communities.
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From page 96... ...
The potential for effective health communication and key messages to the public to modify beliefs and influence behavior has been recognized by the public health community for many years. In order to drive effective messaging, public health agencies and others responsible for population health improvement should fully engage consumers by presenting health information in effective formats that drive improved outcomes and also extend reach through utilization of emerging venues of communication such as social networks and other new media mechanisms.
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From page 97... ...
2008. Population health and health information technology framework: Defini tions, conceptual model, and principles.
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From page 98... ...
Journal of Public Health Management and Practice 7(6)
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