The Community As A Learning Health System

Larry A. Green, MDUniversity of Colorado Denver

September 20, 2012

May 2012

This Presentation

• Recall some things we think we know that might guide further practice based research.

• Offer some “passages” that may be connections between where we have been and where we probably need to go.

• Call out the potential of communities as learning health systems.

• Nominate three recent reports and some possible “rules for the road” that WREN may find useful in setting its further compass headings.

• Conclude with a bit of poetry.

Reasons Americans Die Prematurely

5McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA

2004;291:1230-1245.

40% is due to health-related behaviors. Since we know that health behaviors can be changed, it follows that programs of health behavior change should be systematically incorporated into any plan for comprehensive health care

A Primary Care Perspective:The 2000 Ecology. Green et al NEJM 2001

The Evidence: Primary Care Improves Population Health

Outcomes

• Primary care improves effectiveness.• Primary care improves efficiency.• Primary care improves equity.• Generic outcomes are better in systems with

stronger primary care • No study shows otherwise.

Starfield. Milbank Quarterly, 2005

Practice-Based Research Networks (PBRNs)

Number of AHRQ-registered PBRNs: 136 (as of July 2012)– 116 primary care PBRNs – 20 affiliate PBRNs (non-primary care and international networks)

Descriptive information about primary-care PBRNs (N = 116)– Patient population: 48 million across all 50 states

Network coverage:

• 28% regional • 29% state• 28% local• 15% national

Network type:

• 44% mixed

• 35% family medicine

• 13% pediatric • 5% internal

medicine• 3% nursing

Number of primary care practices: 11,500

• Average/median number of practices per PBRN: 99/34

• 44,800 individual network members

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Practice-Based Research Networks (PBRNs)

Descriptive information about primary care PBRNs (N = 116)– 70% of practices have used electronic medical records for research purposes– 73% of practices have collaborated with another PBRN or plan– Average/median number of studies conducted in the past year: 5.1/3

Most common study designs:

• Health systems/outcomes research

• Observational epidemiology

• Best practices research

Health conditions most commonly studied:

• Diabetes• Obesity• Pulmonary

disease/asthma• Cardiovascular

disease

One View of Critical Passages

From what –to—what?

wHealthcare Healthcare

Commercialism ProfessionalismProfit Healthy CommunitiesTechnicians/Lineworkers Personal PhysiciansMore! Enough! Volume! Value!Produce Inequities Relieve Disparitites

Fragmentation Integration

Shrinking Scope Comprehensive ScopePH+MH+PC+FM Reunited-Integrated PlatformBiologic Science All Relevant Science Little Data Big DataFuzzy Boundaries Multilateral CompactsPay for Fragments Blended/Bundled Payment

Chess Jigsaw Puzzle

Heroic Physician Championship TeamWeak Infrastructure New InfrastructurePassive Recipients Voracious ExplorersRandomizing Confounders Using Confounders

Shaping a Health Statistics Vision for the 21st Century (2002)

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Pharmaceutical Firm

Beacon Community

IntegratedDelivery System

Community Practice

Health Information Organization

Health CenterNetwork

FederalAgencies

State Public Health

GovernanceEngagementStandardsTrustAnalysisDissemination

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A Learning Health System

Privacy Education

Ethical Use

Security

Data Integrity

Research Data Analysis

Workforce

Data Standards

LEARNING HEALTH SYSTEM

Information on health and health care

HEALTH DATA STEWARDSHIP

Health Data Stewardship: What, Why, Who, How-- An NCVHS Primer (2009)

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Published, November 2011Joint Project of the Population Health and Privacy, Security and Confidentiality Subcommittees

Health is a Community Affair

“Getting data into the hands of communities and ensuring they have tools and capacities to use them could move the nation toward

realizing the public benefits of the informatics revolution.”

The Community as a Learning System for Health, NCVHS, December 2011, p. 7

SUCCESS FACTORS IN COMMUNITY LEARNING SYSTEMS FOR HEALTH

1. A galvanizing health concern.

2. A comprehensive understanding of health and community health.

3. Collaborative culture; social capital.

4. Trust and community engagement.

5. Access to data on local health and its determinants, plus analytic capacities.

6. Data display and dissemination capacities.

7. Functioning coalitions, community engagement, agreement on priorities.

8. Organizational and technical support.

9. Political and financial support.

10. Processes and systems to translate information and priorities into action, evaluate results, and modify as needed.

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Institute of MedicineMarch 28, 2012

• Integration of primary care and public health could enhance the capacity of both sectors to carry out their missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health

• The committee finds that in its current state, the infrastructure for both primary care and public health is inadequate to achieve the nation’s population health objectives.

• No single best solution for achieving integration can be prescribed . . . will require substantial local adaptation

Communities of Solution: The 1967 FolsomReport Revisited, May/June 2012

13 Contemporary Grand Challenges comprising an integrated action plan to re-invigorate community-centered health systems.

The Personal Physician+PCMH=“True Public Health Professional”

Grand challenge 2: Foster the ongoing development of integrated, comprehensive care practices (patient-centered medical homes), accessible for all groups in a community, through the creation of explicit partnerships with public health professionals and communities of solution

Why Are We On This Journey?

Because our people are waiting for us to make the trip and show up —as the best personal physicians, working from a robust and efficient platform, achieving the primary care function that is essential to sustainable, high performance healthcare.

Rules for the Road

• Health, the foundation for achievement, is our goal.

• It is not so much a battle against disease as a “quest for long, healthy, meaningful lives.”

• Personal doctoring is our cornerstone method, a relationship, not a commodity.

Rules for the Road

• Never sacrifice alignment with public good for professional gain.

• Never forget rural populations.• There is no one among us unworthy of health

care.• Being the best never goes out of style.

Thank You--for Being You andDoing What YOU Do!