Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Health Research Policy and Systems
Published in: Health Research Policy and Systems 1/2019

Open Access 01-12-2019 | Care | Research

A framework for value-creating learning health systems

Authors: Matthew Menear, Marc-André Blanchette, Olivier Demers-Payette, Denis Roy

Published in: Health Research Policy and Systems | Issue 1/2019

Login to get access

Abstract

Background

Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs.

Methods

The framework was developed by an interdisciplinary team at the Institut national d’excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts.

Results

The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs’ strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs.

Conclusions

Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.
Appendix
Available only for authorised users
Literature
1.
World Economic Forum. Value in Healthcare: Laying the Foundation for Health System Transformation. Geneva: World Economic Forum; 2017.
2.
3.
Dzau VJ, McClellan MB, McGinnis JM, Finkleman EM. Vital Directions for Health and Healthcare: An Initiative of the National Academy of Medicine. Washington, DC: National Academy of Medicine; 2017.
4.
5.
Wheeler SB, Spencer J, Rotter J. Toward value in health care: perspectives, priorities, and policy. N C Med J. 2018;79(1):62–5.PubMed
6.
Porter ME. A strategy for health care reform--toward a value-based system. N Engl J Med. 2009;361(2):109–12.PubMedCrossRef
7.
Institute of Medicine. Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes and Innovation: Workshop summary. Washington, DC: IOM; 2010.
8.
Institute of Medicine. Roundtable on Value and Science-Driven Health Care: The Learning Health System and its Innovation Collaboratives: Update Report. Washington, DC: IOM; 2011.
9.
Institute of Medicine. Making a Difference: Roundtable Charter, Strategy, Tactics, Impact. Washington, DC: IOM; 2014.
10.
11.
Budrionis A, Bellika JG. The learning healthcare system: where are we now? A systematic review. J Biomed Inform. 2016;64:87–92.PubMedCrossRef
12.
Foley T, Fairmichael F. The Potential of Learning Healthcare Systems. Newcastle: Institute of Health and Society; 2015.
13.
Lessard L, Michalowski W, Fung-Kee-Fung M, Jones L, Grudniewicz A. Architectural frameworks: defining the structures for implementing learning health systems. Implement Sci. 2017;12(1):78.PubMedPubMedCentralCrossRef
14.
Canadian Foundation for Healthcare Improvement. Healthcare Priorities in Canada: A Backgrounder. Ottawa: CFHI; 2014.
15.
Alberta Health. Health System Outcomes and Measurement Framework. Edmonton: Alberta Health; 2014.
16.
Bergevin Y, Habib B, Elicksen-Jensen K, Samis S, Rochon J, Denis JL, et al. Transforming regions into high-performing health systems toward the triple aim of better health, better care and better value for Canadians. Healthc Pap. 2016;16(1):34–52.PubMedCrossRef
17.
Health Quality Ontario. Quality Matters: Realizing Excellent Care for All. Toronto: HQO; 2017.
18.
Canadian Institute for Health Information. A Performance Measurement Framework for the Canadian Health System. Ottawa: CIHI; 2013.
19.
Forest PG, Martin D. Fit for Purpose: Findings and Recommendations of the External Review of the Pan-Canadian Health Organizations. Ottawa: Government of Canada; 2018.
20.
Lavis JN, Gauvin FP, Reid RJ, Bullock H, Wodchis WP, Hayes A. Rapid Synthesis: Creating a Rapid-Learning Health System in Ontario. Hamilton: McMaster Health Forum; 2018.
21.
Lavis JN, Gauvin FP, Mattison CA, Moat KA, Waddell K, Wilson MG, et al. Rapid Synthesis: Creating Rapid-Learning Health Systems in Canada. Hamilton: McMaster Health Forum; 2018.
22.
Martin D, Miller AP, Quesnel-Vallee A, Caron NR, Vissandjee B, Marchildon GP. Canada's universal health-care system: achieving its potential. Lancet. 2018;391(10131):1718–35.PubMedCrossRefPubMedCentral
23.
24.
Roy DA, Candas B, Litvak E, Boileau L. The necessary – but not sufficient – leadership of research to transform health systems. Healthcare Papers. 2016;16:S21–5.CrossRef
25.
26.
27.
Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157(3):207–10.PubMedCrossRef
28.
Lowes LP, Noritz GH, Newmeyer A, Embi PJ, Yin H, Smoyer WE, et al. 'Learn from every patient': implementation and early results of a learning health system. Dev Med Child Neurol. 2017;59(2):183–91.PubMedCrossRef
29.
Fung-Kee-Fung M, Maziak DE, Pantarotto JR, Smylie J, Taylor L, Timlin T, et al. Regional process redesign of lung cancer care: a learning health system pilot project. Curr Oncol. 2018;25(1):59–66.PubMedPubMedCentralCrossRef
30.
Psek WA, Stametz RA, Bailey-Davis LD, Davis D, Darer J, Faucett WA, et al. Operationalizing the learning health care system in an integrated delivery system. EGEMS. 2015;3(1):1122.PubMedPubMedCentralCrossRef
31.
Mandl KD, Kohane IS, McFadden D, Weber GM, Natter M, Mandel J, et al. Scalable Collaborative Infrastructure for a Learning Healthcare System (SCILHS): architecture. J Am Med Inform Assoc. 2014;21(4):615–20.PubMedPubMedCentralCrossRef
32.
Marsolo K, Margolis PA, Forrest CB, Colletti RB, Hutton JJ. A digital architecture for a network-based learning health system: integrating chronic care management, quality improvement, and research. EGEMS. 2015;3(1):1168.PubMedPubMedCentralCrossRef
33.
Ainsworth J, Buchan I. Combining health data uses to ignite health system learning. Methods Inf Med. 2015;54(6):479–87.PubMedCrossRef
34.
Ovretveit J, Nelson E, James B. Building a learning health system using clinical registers: a non-technical introduction. J Health Organ Manag. 2016;30(7):1105–18.PubMedCrossRef
35.
Ethier JF, McGilchrist M, Barton A, Cloutier AM, Curcin V, Delaney BC, et al. The TRANSFoRm project: experience and lessons learned regarding functional and interoperability requirements to support primary care. Learning Health Systems. 2017;2(2):e10037.PubMedPubMedCentralCrossRef
36.
Daniel C, Ouagne D, Sadou E, Paris N, Hussain S, Jaulent MC, et al. Cross border semantic interoperability for learning health systems: the EHR4CR semantic resources and services. Learning Health Systems. 2017;1:e10014.PubMedCrossRef
37.
Senge P. The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday; 2006.
38.
Alderwick H, Ham C, Buck D. Population Health Systems: Going Beyond Integrated Care. London: The King’s Fund; 2015.
39.
40.
Romanow R. Building on Values: The Future of Health Care in Canada. Government of Canada: Ottawa; 2002.
41.
Fattore G, Tediosi F. The importance of values in shaping how health systems governance and management can support universal health coverage. Value Health. 2013;16(1 Suppl):S19–23.PubMedCrossRef
42.
Culyer AJ. Social Values in Health and Social Care. London: The King’s Fund; 2014.
43.
Brooks D, Douglas M, Aggarwal N, Prabhakaran S, Holden K, Mack D. Developing a framework for integrating health equity into the learning health system. Learning Health Systems. 2017;1:e10029.PubMedPubMedCentralCrossRef
44.
Advisory Panel on Healthcare Innovation. Unleashing Innovation: Excellent Healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. Ottawa: Government of Canada; 2015.
45.
Wass S, Vimarlund V. Healthcare in the age of open innovation – a literature review. Health Inf Manag. 2016;45(3):121–33.PubMed
46.
47.
Pronovost PJ, Mathews SC, Chute CG, Rosen A. Creating a purpose-driven learning and improving health system: the Johns Hopkins Medicine quality and safety experience. Learning Health Systems. 2017;1:e10018.PubMedCrossRef
48.
Starren JB, Winter AQ, Lloyd-Jones DM. Enabling a learning health system through a unified enterprise data warehouse: the experience of the Northwestern University Clinical and Translational Sciences (NUCATS) Institute. Clin Transl Sci. 2015;8(4):269–71.PubMedPubMedCentralCrossRef
49.
50.
PCORnet Consortium, Daughtery SE, Wahba S, Fleurence R. Patient-powered research networks: building capacity for conducting patient-centered clinical outcomes research. J Am Med Inform Assoc. 2014;21:583–6.CrossRef
51.
Noseworthy T, Wasylak T, O'Neill B. Strategic clinical networks in Alberta: structures, processes, and early outcomes. Healthc Manage Forum. 2015;28(6):262–4.PubMedCrossRef
52.
53.
54.
Institute of Medicine. Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care. Workshop Series Summary. Washington, DC: IOM; 2011.
55.
56.
Marsolo K. In search of a data-in-once, electronic health record-linked, multicenter registry – how far we have come and how far we still have to go. EGEMS. 2013;1(1):1003.PubMedPubMedCentralCrossRef
57.
Wallace PJ, Shah ND, Dennen T, Bleicher PA, Crown WH. Optum Labs: building a novel node in the learning health care system. Health Aff. 2014;33(7):1187–94.CrossRef
58.
Amin W, Tsui FR, Borromeo C, Chuang CH, Espino JU, Ford D, et al. PaTH: towards a learning health system in the Mid-Atlantic region. J Am Med Inform Assoc. 2014;21(4):633–6.PubMedPubMedCentralCrossRef
59.
Turley CB, Obeid J, Larsen R, Fryar KM, Lenert L, Bjorn A, et al. Leveraging a statewide clinical data warehouse to expand boundaries of the learning health system. EGEMS. 2016;4(1):1245.PubMedPubMedCentralCrossRef
60.
Johnson LC, Melmed GY, Nelson EC, Holthoff MM, Weaver SA, Morgan TS, et al. Fostering collaboration through creation of an IBD learning health system. Am J Gastroenterol. 2017;112(3):406–8.PubMedCrossRef
61.
McGlynn EA, Lieu TA, Durham ML, Bauck A, Laws R, Go AS, et al. Developing a data infrastructure for a learning health system: the PORTAL network. J Am Med Inform Assoc. 2014;21(4):596–601.PubMedPubMedCentralCrossRef
62.
Forrest CB, Margolis PA, Bailey LC, Marsolo K, Del Beccaro MA, Finkelstein JA, et al. PEDSnet: a national pediatric learning health system. J Am Med Inform Assoc. 2014;21(4):602–6.PubMedPubMedCentralCrossRef
63.
Schilsky RL, Michels DL, Kearbey AH, Yu PP, Hudis CA. Building a rapid learning health care system for oncology: the regulatory framework of CancerLinQ. J Clin Oncol. 2014;32(22):2373–9.PubMedCrossRef
64.
Finney Rutten LJ, Alexander A, Embi PJ, Flores G, Friedman C, Haller IV, et al. Patient-centered network of learning health systems: developing a resource for clinical translational research. J Clin Transl Sci. 2017;1(1):40–4.PubMedPubMedCentralCrossRef
65.
Blumenthal D, Tavenner M. The ‘meaningful use’ regulation for electronic health records. N Engl J Med. 2010;363(6):501–4.PubMedCrossRef
66.
67.
Burde H. The HITECH Act – An overview. Am Med Assoc J Ethics. 2011;13(3):172–5.
68.
Yu PP. Perspectives on the implementation of an ethical rapid learning health system. J Oncol Pract. 2017;13(3):151–3.PubMedCrossRef
69.
Forrest CB, Chesley FD Jr, Tregear ML, Mistry KB. Development of the learning health system researcher core competencies. Health Serv Res. 2018;53(4):2615–32.PubMedCrossRef
70.
71.
Zelmer J. Digital drivers in a learning health system: considerations for research innovation. Healthcare Papers. 2016;16(Special issue):36–41.
72.
Deeny SR, Steventon A. Making sense of the shadows: priorities for creating a learning healthcare system based on routinely collected data. BMJ Qual Saf. 2015;24(8):505–15.PubMedPubMedCentralCrossRef
73.
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: IOM; 2013.
74.
75.
Canadian Institutes of Health Research. Evaluation of the Strategy for Patient-Oriented Research - Final Report. Ottawa: CIHR; 2016.
76.
Morain SR, Kass NE, Grossman C. What allows a health care system to become a learning health care system: results from interviews with health system leaders. Learning Health Systems. 2017;1:e10015.PubMedCrossRef
77.
Reid RJ. Embedding research in the learning health system. Healthcare Papers. 2016;16(Special issue):30–5.
78.
Eriksson JK, Askling J, Arkema EV. The Swedish Rheumatology Quality Register: optimisation of rheumatic disease assessments using register-enriched data. Clin Exp Rheumatol. 2014;32(5 Suppl 85):S147–9.
79.
Delaney BC, Curcin V, Andreasson A, Arvanitis TN, Bastiaens H, Corrigan D, et al. Translational medicine and patient safety in Europe: TRANSFoRm – architecture for the learning health system in Europe. Biomed Res Int. 2015;2015:961526.PubMedPubMedCentralCrossRef
80.
Suarez-Mejias C, Martinez-Garcia A, Martinez-Maestre MA, Silvan-Alfaro JM, Moreno Conde J, Parra-Calderon CL. Learning healthcare system for the prescription of genetic testing in the gynecological cancer risk. Stud Health Technol Inform. 2017;235:96–100.PubMed
81.
Krumholz HM. Big data and new knowledge in medicine: the thinking, training, and tools needed for a learning health system. Health Aff. 2014;33(7):1163–70.CrossRef
82.
Friedman CP, Wong AK, Blumenthal D. Achieving a nationwide learning health system. Sci Transl Med. 2010;2(57):57cm29.PubMedCrossRef
83.
84.
Faden RR, Kass NE, Goodman SN, Pronovost P, Tunis S, Beauchamp TL. An ethics framework for a learning health care system: a departure from traditional research ethics and clinical ethics. Hastings Cent Rep. 2013;Spec No:S16–27.PubMedCrossRef
85.
Flynn AJ, Friedman CP, Boisvert P, Landis-Lewis Z, Lagoze C. The Knowledge Object Reference Ontology (KORO): a formalism to support management and sharing of computable biomedical knowledge for learning health systems. Learning Health Systems. 2018;2:e10054.PubMedPubMedCentralCrossRef
86.
Baek EO, Cagilty K, Boling E, Frick T. User-centered design and development. In: Spector JM, Merrill D, van Merrienboer J, editors. Handbook of Research on Educational Communications and Technology (3rd edition). Abingdon: Routledge; 2008.
87.
Kakabadse NK, Kakabadse A, Kouzmin A. Reviewing the knowledge management literature: towards a taxonomy. J Knowl Manag. 2003;7(4):75–91.CrossRef
88.
Alavi M, Leidner DE. Knowledge management and knowledge management systems: conceptual foundations and research issues. MIS Q. 2001;25(1):107–36.CrossRef
89.
Choo CW. The knowing organization: how organizations use information to construct meaning, create knowledge and make decisions. Int J Inf Manag. 1996;16(6):329–40.CrossRef
90.
Weick KE. Sensemaking in Organizations. Thousand Oaks: Sage Publications; 1995.
91.
Nonaka I, Takeuchi H. The Knowledge-Creating Company. New York: Oxford University Press; 1995.
92.
93.
Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med. 2012;43(3):337–50.PubMedPubMedCentralCrossRef
94.
Dickson G, Lindstrom R, Black C, Van der Gucht D. Evidence-Informed Change Management in Canadian Healthcare Organizations. Ottawa: Canadian Health Services Research Foundation; 2012.
95.
Iles V, Sutherland K. Organisational Change: A Review for Health Care Managers, Professionals, and Researchers. London: National Co-ordinating Centre for NHS Service Delivery and Organisation; 2001.
96.
Kotter J. Leading Change. Cambridge: Harvard Business Review Press; 2012.
97.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.PubMedPubMedCentralCrossRef
98.
Leeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond ‘implementation strategies’: classifying the full range of strategies used in implementation science and practice. Implement Sci. 2017;12(1):125.PubMedPubMedCentralCrossRef
99.
Powell BJ, Beidas RS, Lewis CC, Aarons GA, McMillen JC, Proctor EK, et al. Methods to improve the selection and tailoring of implementation strategies. J Behav Health Serv Res. 2017;44(2):177–94.PubMedPubMedCentralCrossRef
100.
Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21.PubMedPubMedCentralCrossRef
101.
Michie S. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev. 2012;6(1):1–6.CrossRef
102.
Proctor E, Luke D, Calhoun A, McMillen C, Brownson R, McCrary S, et al. Sustainability of evidence-based healthcare: research agenda, methodological advances, and infrastructure support. Implement Sci. 2015;10:88.PubMedPubMedCentralCrossRef
103.
Schön D. The Reflective Practitioner. New York: Basic Books; 1983.
104.
Argyris C, Schön D. Organizational Learning: A Theory of Action Perspective. Reading: Addison Wesley; 1978.
105.
Ebbevi D, Forsberg HH, Essen A, Ernestam S. Value-based health care for chronic care: aligning outcomes measurement with the patient perspective. Qual Manag Health Care. 2016;25(4):203–12.PubMedPubMedCentralCrossRef
106.
107.
Tseng EK, Hicks LK. Value based care and patient-centered care: divergent or complementary? Curr Hematol Malig Rep. 2016;11(4):303–10.PubMedCrossRef
108.
109.
Bhandari RP, Feinstein AB, Huestis SE, Krane EJ, Dunn AL, Cohen LL, et al. Pediatric-Collaborative Health Outcomes Information Registry (Peds-CHOIR): a learning health system to guide pediatric pain research and treatment. Pain. 2016;157(9):2033–44.PubMedPubMedCentralCrossRef
110.
Peckham A, Rudoler D, Bhatia D, Fakim S, Allin S, Marchildon G. Accountable Care Organizations and the Canadian Context. Rapid Review (No. 9). Toronto: North American Observatory on Health Systems and Policies; 2018.
111.
Canada Health Infoway. Canada Health Infoway Annual Report 2017–2018. Toronto: CHI; 2018.
112.
Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician. 2015;61:1076–84.PubMedCentral
113.
Noonan VK, Thorogood NP, Joshi PB, Fehlings MG, Craven BC, Linassi G, et al. Meeting the privacy requirements for the development of a multi-centre patient registry in Canada: the Rick Hansen Spinal Cord Injury Registry. Healthc Policy. 2013;8(4):87–99.PubMedPubMedCentral
114.
Kotecha JA, Manca D, Lambert-Lanning A, Keshavjee K, Drummond N, Godwin M, et al. Ethics and privacy issues of a practice-based surveillance system: need for a national-level institutional research ethics board and consent standards. Can Fam Physician. 2011;57(10):1165–73.PubMedPubMedCentral
115.
Tamblyn R, McMahon M, Nadigel J, Dunning B, Drake E. Health system transformation through research innovation. Healthcare Papers. 2016;16:8–19.
116.
Canadian Institute for Health Information. Patient-Centred Measurement and Reporting in Canada: Launching the Discussion Toward a Future State. Ottawa: CIHI; 2017.
117.
Farmanova E, Kirvan C, Verma J, Mukerji G, Akunov N, Phillips K, et al. Triple aim in Canada: developing capacity to lead to better health, care and cost. Int J Qual Health Care. 2016;28(6):830–7.PubMed
118.
Ryan BL, Brown JB, Glazier RH, Hutchison B. Examining primary healthcare performance through a triple aim lens. Healthc Policy. 2016;11(3):19–31.PubMedPubMedCentral
119.
Institut national d'excellence en santé et en services sociaux. Plan triennal d'activités 2016-2019. Québec: INESSS; 2016.
Metadata
Title
A framework for value-creating learning health systems
Authors
Matthew Menear
Marc-André Blanchette
Olivier Demers-Payette
Denis Roy
Publication date
01-12-2019
Publisher
BioMed Central
Keyword
Care
Published in
Health Research Policy and Systems / Issue 1/2019
Electronic ISSN: 1478-4505
DOI
https://doi.org/10.1186/s12961-019-0477-3

Other articles of this Issue 1/2019

Health Research Policy and Systems 1/2019 Go to the issue

Commentary

Studying social accountability in the context of health system strengthening: innovations and considerations for future work

Research

Hepatitis C virus-related policy-making in Iran: a stakeholder and social network analysis

Review

A literature review of knowledge translation and partnership research training programs for health researchers

Research

The determinants of vaccination in a semi-rural area of Vientiane City, Lao People’s Democratic Republic: a qualitative study

Research

Fostering access to and use of contextualised knowledge to support health policy-making: lessons from the Policy Information Platform in Nigeria

Review

A checklist for designing health insurance programmes – a proposed guidelines for Nigerian states