Training & The Learning Healthcare System

Posted by Todd Borghesani

What follows was excerpted from Institute of Medicine Roundtable on Evidence-Based Medicine, “The Learning Healthcare System.” As we think strategically about training future healthcare professionals, the training industry will need to design interventions and tools based on dramatic increases in just-in-time bioinformation.

The United States can develop a rapid learning healthcare system. New research capabilities now emerging—large electronic health record databases, predictive computer models, and rapid learning networks—will make it possible to advance clinical care from the experience of tens of millions of patients each year. With collaborative initiatives in the public and private sectors, a national goal could be for the health system to learn about the best uses of new technologies at the same rate that it produces new technologies. This could be termed a rapid learning health system (Health Affairs 2007).

In a system that increasingly learns from data collected at the point of care and applies the lessons for patient care improvement, healthcare professionals will continue to be the linchpin of the front lines, assessing the needs, directing the approaches, ensuring the integrity of the tracking and the quality of the outcomes, and leading innovation. However, what these practitioners will need to know and how they learn will dramatically change.

For example, to keep up with germane developments in the field of internal medicine, physicians now face the prospect of learning from thousands of relevant articles being published each month. Not surprisingly, numb resignation may supplant the desired eager and interactive approach to lifelong learning. Unfortunately, physicians are doing a mediocre job of delivering recommended care to patients, with one well-designed study showing success about half the time (McGlynn et al. 2003); national reports confirm this though there are signs of improvement (AHRQ 2003).

EHRs enable change in the practice ecosystem (Stead 2007). They change roles and responsibilities, what the clinician needs to know, and how the clinician learns, while providing a new source of information. These changes are discontinuous, not an incremental improvement in what we do today. Hence, conversations about using the EHR are not generally focused on issues of providing evidence to, or generating evidence from, our current practice processes. Yet let us consider nine ways the EHR and clinical informatics tools could potentially be used to generate and apply evidence: using billing data to identify variability in practice; EHR data to direct care; EHR data to relate outcomes back to practice; EHR data to monitor open- loop processes; decision support systems for alerts and reminders within clinical workflow; decision support systems for patient-specific alerts to change in practice; decision support systems for links to evidence within clinical workflow; de-identified EHR data to detect unexpected events; and de-identified EHR and Biobank data for phenotype-genotype hypothesis generation.

Continuing education after initial training plays an essential role in allowing them to apply such new evidence effectively to patient care. The standard approach to postgraduate physician education, traveling to a continuing medical education course and listening to presentations in a classroom setting, is endorsed by medical societies, supported by pharmaceutical companies, and required by many state licensing boards. Yet, previous systematic reviews have documented for decades that standard CME is ineffective at changing physician behavior and translating proven interventions into practice (Haynes et al. 1984; Davis et al. 1995; Davis et al. 1999).

While these typical didactic sessions unsuccessfully influence practice, interactive workshops (e.g., role playing, case discussion, practicing skills) do seem to generate changes in performance and offer hope (O’Brien et al. 2006). A variant of CME, continuous professional development, has been advocated by the American Board of Internal Medicine and attempts to incorporate adult learning principles and reflection (Baron 2005), but its economic value is yet to be determined (Brown et al. 2002). Additionally, it employs self-directed learning as a principal method, but physicians have limited ability to self-assess their own competency (Davis et al. 2006). All of these approaches to continuing education tend to focus on the physician to the exclusion of other members of the healthcare team. Team-based simulation training and the use of immersive technologies offers the most powerful platform for learning.

The above figure depicts how a systems approach to learning might work. At its center is assessment. The system would decide if the clinician knows what she needs to know to do what she is going to do next. If the answer is yes, based on her learning and outcome records, she proceeds to perform the clinical task (right-hand circle). Her knowledge of how to use facts is assisted by computer recall of details, such as specific drug-drug interactions. Electronic records track the patient’s progress and provide feedback regarding the effectiveness of the “system” and the clinician. After each cycle of clinical performance, her competency is reassessed. She flips into the learn cycle (left-hand circle) whenever additional knowledge or improvement is needed. The learn cycle begins by assembling a targeted curriculum.

Next she reads and assimilates the information. Finally, she uses simulation to test understanding and technical skill. The simulator pushes her past her limit of competency, ensuring individual understanding of that boundary. The simulator takes her back to the assessment point. If knowledge and skill are adequate, she flips back over into the performance mode. If not, she repeats the learn cycle.

With the formation of a Committee on Innovation in the Learning Environment, the Accreditation Council for Graduate Medical Education seeks to achieve implementation of the expectation that physicians be taught six general competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice (Batalden et al. 2002). This forces a shift from residents’ learning predominantly through clinical experiences to also include an emphasis on mastering and leading systems that deliver safe care (Leach and Philibert 2006). Fortunately, multiple quality improvement strategies, including some with robust research supporting their efficacy (e.g., audit and feedback), are available to be utilized in this effort (Stein 2006).

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