Improving health outcomes and making the delivery system more effective rely on meaningful collaboration of patients, providers, and teams. Health care is improving, but more change is needed.1 Since the 1990s, organizational learning has been promoted as a change management process,2 and these principles have made their way into health care. Learning health care systems (LHSs) are organizations where "science, informatics, incentives, and culture are aligned for continuous improvement and innovation."3 In 2013, the Institute of Medicine proposed that health care organizations transform into learning systems characterized by effective integration of science and informatics, patient-clinician partnerships, incentives, and culture.4 Many institutions, including Johns Hopkins Medicine, have created leadership and structural systems to promote learning, accountability, and change.5
Primary care providers (PCPs) have a unique role within an LHS. In addition to first contact, prevention, coordination, and stewardship, PCPs provide the majority of care to patients with chronic, complex illnesses. Through partnerships with providers, researchers, and educators, PCPs can improve care and enhance performance of the entire LHS. Primary care providers perceive that lack of time is the biggest barrier to safe, high-quality practice.6 Working with top-of-license support teams is a suggested solution to the provider time crunch. For example, our clinical support teams are responsible for completing more than 15 standard intake processes; we delegate other processes based presenting complaints of patients. However, clinical support staff may lack competency in basic clinical skills and knowledge, making it difficult, if not unsafe, to delegate more care.7
Johns Hopkins Community Physicians employs more than 1300 individuals, including 240 clinicians who provide primary care to more than 250 000 patients. We have central management functions coordinating quality, safety, operations, information technology, and research and education, and consider ourselves an LHS in evolution. We have implemented specific education initiatives in our primary care group and describe them below to stimulate discussion and change in other health systems. The Table maps these initiatives to the Institute of Medicine LHS characteristics.
PROMOTE USE OF INFORMATICS AND DATA THROUGH EFFECTIVE ELECTRONIC HEALTH RECORD USE
Electronic health record (EHR) systems, powered by analytics, big data, and information exchange, are the technical workhorses of the LHS. Increased use of EHRs over the last 2 decades has made data-informed decision support and other quality improvement functionality available at the point of care. The usability and design of these systems are improving, but even the best EHR systems require high-quality education and training to ensure that they are used to their potential.8
To use EHRs effectively, clinicians need training from experts who can teach context and interpretation, and how to use important functionalities most effectively. We have engaged clinician experts to develop and deliver high-quality EHR-related training together with training professionals and have found that the collaboration enhances the knowledge and skills of the entire team. As EHR capabilities in decision support and intelligent orders have evolved, we have provided both optional and required-interval education, using multiple modalities, to promote effective use of the EHR tool kit for care improvement.
Digital capture of the care experience is another foundational element of the LHS. Yet, health care providers receive little education on front-end data input elements, such as diagnostic coding and discoverable data elements. In addition, support staff charged with data collection may lack the skills to elicit and document key data elements. Both providers and staff may be tasked with collecting information without knowing about the performance improvement context of that data. Because LHS learning cycles rely on accurate data, we have assigned quality analysts and educators to work with frontline clinical teams to explain key performance indicators and their data definitions. This promotes transparency and performance.
TRAIN THE TEAM TO SUPPORT PATIENT RELATIONSHIPS AND EXPERIENCE
Like many organizations, we have used surveys (CG-CAHPS) and other metrics to assess patient experience and have developed new leadership, structure, training, and education to enhance relationships among patients, providers, and care teams. We recruited a patient experience officer who leads education and other experience-related initiatives. Over the past 2 years, all of our ambulatory practices have engaged providers and staff in team-based training using a standard curriculum (Language of Caring@) and central resources. The program is well regarded, and we have seen ongoing improvements in patient experience metrics.
BUILD CULTURE THROUGH TEAM-BASED LEARNING AND COACHING
Effective team-based education, covering EHR efficiency, patient experience, and performance targets, is fundamental to ensuring that teams work effectively together. Health systems need to train providers and staff together to ensure that they share a joint understanding of standard operating procedures, communication standards, and roles and responsibilities for shared tasks. We recently combined team-based skills training with the use of staff-provider agreements that set expectations and provide regular feedback between providers and support staff.
Coaching can enhance the learning environment and assist consolidation of new knowledge and skills. In the last 3 years, we have made systematic investments in provider and staff coaching. A new primary care academy has cultivated a group of provider coaches and created standard clinical observation and feedback tools to facilitate work with PCPs. In parallel, we have invested in coaching support staff through learning cohorts. Early outcomes for both new efforts are encouraging.
PROMOTE LEARNING WITH INCENTIVES
In addition to providing incentives for outcomes and productivity, health systems should invest in incentives to promote engagement in learning activities. We recognize provision of continuing education and maintenance of certification credits to providers is the standard method. We have also provided financial incentives to encourage learning. For example, our system has given providers a $500 bonus when they invested a personal half-day to complete EHR upgrade training, with additional incentives for structured coaching of colleagues and staff.
As we invest in improving health care across the United States, we must assist the transformation of our primary care organizations into learning systems. Better education and training can support our clinical teams as they move through cycles of learning. Leadership can support this change by engineering LHS characteristics into new systems. Addressing other synergies that support systematic learning will be essential as we progress.
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