The Community As A Learning
Health System
Larry A. Green, MD
University 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
 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
McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.
5
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.
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:
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•
•
•
28% regional
29% state
28% local
15% national
Network type:
•
•
•
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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
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
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One View of Critical Passages
From what –to—what?
wHealthcare
Healthcare
Commercialism
Professionalism
Profit
Healthy Communities
Technicians/Lineworkers
Personal Physicians
More!
Enough!
Volume!
Value!
Produce Inequities
Relieve Disparitites
Fragmentation
Shrinking Scope
PH+MH+PC+FM
Biologic Science
Little Data
Fuzzy Boundaries
Pay for Fragments
Integration
Comprehensive Scope
Reunited-Integrated Platform
All Relevant Science
Big Data
Multilateral Compacts
Blended/Bundled Payment
Chess
Jigsaw Puzzle
Heroic Physician
Championship Team
Weak Infrastructure
New Infrastructure
Passive Recipients
Voracious Explorers
Randomizing Confounders
Using Confounders
Shaping a Health Statistics Vision for
the 21st Century (2002)
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A Learning Health System
State Public Health
Pharmaceutical Firm
Community
Practice
Beacon
Community
Federal
Agencies
Governance
Engagement
Standards
Trust
Analysis
Dissemination
Integrated
Delivery
System
Health Information Organization
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Health Center
Network
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HEALTH DATA STEWARDSHIP
Privacy
Education
Data Integrity
Research
Ethical
Use
LEARNING HEALTH
SYSTEM
Information on health
and health care
Data
Analysis
Workforce
Data Standards
Security
Health Data Stewardship: What, Why, Who, How-- An NCVHS Primer (2009)
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Published, November 2011
Joint 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.
6.
2.
A comprehensive understanding of
health and community health.
Data display and dissemination
capacities.
7.
3.
Collaborative culture; social
capital.
Functioning coalitions, community
engagement, agreement on
priorities.
8.
Organizational and technical
support.
9.
Political and financial support.
4.
Trust and community engagement.
5.
Access to data on local health and
its determinants, plus analytic
capacities.
10. Processes and systems to translate
information and priorities into
action, evaluate results, and
modify as needed.
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Institute of Medicine
March 28, 2012
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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 Folsom
Report 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 and
Doing What YOU Do!