Minnesota as a Learning Health System
United States per capita healthcare spending is more than two times the average of other developed nations, yet health outcomes are generally no better, and in some cases are worse. This is where learning health systems, a model where research, care delivery and continuous improvement are seamlessly integrated to create new knowledge and improve care, can help. The University of Minnesota Center for Learning Health System Sciences (CLHSS), a partnership between the Medical School and the School of Public Health that launched in August 2021, aims to address some of these challenges by leveraging existing evidence, gathering new knowledge from care delivery and rapidly implementing innovations into direct population health action.
“Our goal is to decrease the time it takes for science to make it directly into patient care and for evidence to be generated directly from care delivery,” said Genevieve Melton-Meaux, MD, PhD, professor in the Department of Surgery, director of CLHSS and chief analytics and care innovation officer at M Health Fairview. “Our experience with COVID-19 created an important opportunity to see a learning health system in action, where evidence-based care delivery, research and innovation were brought closely together to provide optimal care for the patients we serve.”
Because of its critical nature, the COVID-19 pandemic reinforced the need to apply rapid-cycle learning with evidence changing overnight. This has involved synthesizing evidence and translating it into clinical practice, like COVID-19 clinical trials using repurposed drugs, care guidelines for emergency physicians, using artificial intelligence to analyze chest X-rays, understanding racial and ethnic disparities for severe COVID-19 disease, expanding and evaluating inpatient virtual care and remote patient monitoring of COVID-19 disease.
“One of our CLHSS scholars took on the problem of blood thinners and their use with COVID-19 from around the country to develop an algorithm with the best evidence for patient care,” said Bradley Benson, MD, professor in the Department of Medicine’s Division of General Internal Medicine and chief academic officer for M Health Fairview. “Using the learning health systems approach, we were able to embed the algorithm into our electronic health record, ensuring that every patient with COVID received the best possible care.”
The learning health systems approach led to better outcomes, fewer patients in the intensive care unit and saved lives by reducing bleeding complications – a process CLHSS hopes to duplicate and expand. In addition to embedded researchers, the center’s approach also leverages data to assess performance, creating a feedback cycle for learning and improvement. These findings are synthesized into evidence to address clinical challenges and then applied in the care delivery process. The model is reinforced through a combination of rigorous dissemination and implementation approaches, as well as aligning incentives, leadership and culture with clinical partners.
“We developed the center to help catalyze research and remove barriers for health system-based work to continuously improve outcomes for our patients, ultimately making the health system a ‘living laboratory’ with the latest evidence and innovation,” Dr. Benson said. “It’s all about value creation — the value we want to create has better outcomes for our patients, better experiences for both patients and providers and a lower cost of care.”
To accelerate bringing innovations from bench to bedside, which traditionally takes an average of 17 years, the CLHSS is deploying a Rapid Prospective Evaluation Unit (RapidEval) aimed at quickly developing rigorous evidence around healthcare practices. University faculty, learners, staff and health system partners can submit proposals to test existing or new practices that have a direct impact on patient care and leverage the center’s expertise to scale interventions.
“One of our goals is to solicit really good ideas from our communities and refine the ones with the best chance of impacting the most people,” Dr. Benson said. “The key here is that we implement the proposal and collect data within three to six months to prove whether it really delivers or not. If it does, we’ll scale it across the system.”
RapidEval will use a variety of prospective evaluation approaches to test interventions by tailoring study designs and questions to the real world, which will in turn support translation to clinical care across systems.
“The other thing we envision is a practice-based research network (PBRN), which is a network of clinics and clinicians who help with cultural change and translate a project into the processes of each clinic,” Dr. Benson said. “The PBRN also leverages the deep connections that many of our clinics have in our communities so that we can engage in productive and impactful conversations with the populations we serve.”
This includes understanding how research might address questions that are important to the community and then prioritizing those concerns within the research agenda. The practice-based research network is supported through strong collaboration with the Clinical and Translational Science Institute (CTSI).
The Healthcare Innovation Program for Implementation and Evaluation’s (HI-PIE) Evidence Synthesis Unit is another collaboration between CLHSS and the Minnesota Evidence-Based Practice Center. The unit evaluates emerging evidence or evidence gaps to inform and adapt clinical practice and is equipped to answer questions using a critical and rigorous but time-limited approach.
A key component of the CLHSS is the Minnesota Learning Health System Mentored Career Development Program (MN LHS), which embeds faculty trainees to conduct learning health system research directly within health systems to generate, apply and translate evidence into practice seamlessly.
“We needed a process and structure for researchers, clinicians and delivery systems to connect, share ideas and set priorities, and that’s where the center comes in,” said Timothy Beebe, PhD, professor and head of the School of Public Health’s Division of Health Policy and Management and deputy director of the CLHSS. “The center performs a convening function, with practitioners and researchers co-creating knowledge.”
The MN LHS currently trains 12 scholars across healthcare systems in Minnesota and is a partnership between the University of Minnesota, M Health Fairview, Hennepin Healthcare and the Mayo Clinic.
“Our traditional training programs haven’t really equipped researchers with skills necessary to embed in health systems, understanding patient and stakeholder engagement, system science and how these complex components interact and impact health outcomes,” Dr. Beebe said.
Researchers historically engaged in healthcare delivery by working in stand-alone laboratories, but the center’s unique approach places them within health systems alongside a highly interdisciplinary team with diverse constituents instead of in an office or lab at a university.
“We’re trying to treat the state as a learning health system,” Dr. Beebe said. “We’re a land-grant university, and our charge is to improve the human condition and health in Minnesota. That means we can’t study things at an arm’s length — we want to embed in the system and address those thorny questions that are important in medical practice and the scientific community.”
The training program, which is funded through the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute and CTSI, is also setting up structures to facilitate movement between practice and research to better serve patients.
“The center is hoping to get to a point where practice informs knowledge and knowledge informs practice,” Dr. Beebe said. “We want new knowledge to be an integral byproduct of the practice.”
Minnesota as a Learning Health System
The state of Minnesota and the University have a national and international reputation for healthcare innovations — and learning health systems are the next frontier.
“Healthcare is broken, and we need to fix it,” Dr. Benson said. “This center positions us to compete for new and emerging grants — which expect more than just a great scientific paper — but also want to see tangible change in people’s lives.”
The push to effectively develop and deploy medical treatments is reflected in the national funding needle, which is increasingly moving towards learning health system research. Drawing on the breadth of expertise from across the University, CLHSS hopes to incorporate more perspectives and partner systems.
“This center is about our readiness — so much is going in this direction,” Dr. Melton-Meaux said. “This is a platform for faculty to really improve things and transform healthcare.”