The Importance and Challenges of a Learning Healthcare System Friday, May 5th, 2017 Patricia MC Brown Senior Vice President, Managed Care and Population Health, Johns Hopkins Medicine President, Johns Hopkins HealthCare LLC Senior Counsel, Johns Hopkins Health System

Current Healthcare Context Why do we need learning health systems now? Increasing complexity in healthcare Information capture at an all time high Need to sort through complex data to be able to measure and analyze most efficiently and effectively to create actionable information Clinical complexity at an all time high Complexity of clinician interfaces with patients and with health systems Must interact with multiple payors, PCMHs, ACOs, CINs, and other reform efforts each with different requirements and quality measures How to care for patients with multiple, complex chronic conditions plus social needs Source: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

Current Healthcare Context Why do we need learning health systems now? Costs of healthcare Costs of healthcare continue to rise Need to enhance value of healthcare for sustainability Era of healthcare reform in pursuit of the Triple Aim Creates urgency for healthcare transformation efforts to maximize value of care through better use of data, better quality, better alignment of systems Source: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

Current Healthcare Context From: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

Context of Healthcare Transformation Improved connectivity across settings EHRs, HIEs, improved population health management tools Computing power stronger than ever Tools to harness and make use of “Big Data” New organizational arrangements to enhance care delivery Team focused care All care team members working to top of license System level transformation using Learning Health System principles Source: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

What is a Learning Health System? “A learning health system is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.” –IOM 2012 Source: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

Focus Areas for Achieving a Learning Health System The IOM defines focus areas for becoming a learning health system as: Science and Informatics Real-time access to knowledge, digital capture of the care experience Patient-Clinician Partnerships Engaged, empowered patients Incentives Incentives aligned for value, full transparency Culture Leadership-instilled culture of learning, supportive system competencies Source: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2012

Characteristics of a Learning Health Care System In a learning health care system, research influences practice and practice influences research. More specifically, the following areas are key for developing a learning health system: Continuous improvement Learning in health care as a partnership enterprise Developing the point of care as the knowledge engine Full application of information technology Database linkage and use Advancing clinical data as a public utility Building innovative clinical effectiveness research into practice Patient engagement in the evidence process Development of a trusted scientific intermediary Leadership that stems from every quarter Academy Health https://www.academyhealth.org/files/publications/AHUsingEvidence2012.pdf

JHM Leadership has begun Transformation JHM Vision: “Johns Hopkins Medicine will prepare for health care reform by transforming its health care delivery system to become integrated, seamless and patient focused. Our system will be accessible and responsive to community needs resulting in it being the system of choice – constantly demonstrating its ability to be an adaptive learning organization improving the health of the population. It will build on its strong culture and history and leverage its tradition of innovation while improving the science of care delivery.”

Moving JHM towards Transformation using principles of learning health systems

Starting Point: The Problem in Healthcare, and at Johns Hopkins Achieving “The Triple Aim” is not congruent with current business models of US health care organizations and most of the current models within JH Medicine Hospitals….. Seek to improve the quality and experience of the services they provide for their individual patients Not charged with the care of a defined population of patients Not in the acute care hospitals’ best financial interest to reduce costs per capita cost reductions would require significant reductions in high-cost services like hospitalizations and high-technology procedures, the financial lifeblood of hospitals Johns Hopkins Community Physicians and other medical groups…. Interested in the quality of the services they provide Not responsible for the overall health of a population of patients Incentives to reduce per capita costs are absent in a fee-for-service system Johns Hopkins HealthCare…. Responsible for the healthcare of populations Seeks to reduce per capita costs for the people we cover When acting in silos to the JH providers, our leverage to improve health care and patient experience is lower than when acting in tandem

Focus on Science and Informatics Create linkages across sectors EMRs and data systems to generate dashboards that track progress on population health indicators. Promote creation of all-payer claims databases to raise the transparency of data and information so all parties are aware of opportunities to improve performance. Support creation of geographical health information exchanges that incorporate data on social determinants as well as health utilization and outcomes Focus on collection and use of data on social and environmental factors as they related to risk identification and health outcomes Work with community partners to improve data capture and quality Investigate the relative influence of these data in how we understand health and change care for patients Adapted from: Shortell, SM. The Next Frontier: Creating Accountable Communities for Health. Hosp Health Netw. 2015 Jul;89(7):12

Focus on Patient-Clinician Partnerships Improving quality and access to care for patients to enhance patient experience Creating care teams that address social and behavioral needs so that physicians can focus on medical care and patient needs can be met Creating mechanisms to engage patients through wearable technologies, access to their own data, engaging caregivers, and addressing barriers to care Measuring patient satisfaction and working to continuously improve the patient experience

Focus on Aligning Incentives Aligning incentives across providers: CINs Aligning incentives across a health system: ACOs Aligning incentives across health systems to target geographies: Regional partnerships Move to value based payment models Move to align health system around a “patient orientation”

Focus on Culture Creating a mission and vision that are understood and embraced across every part of the health system Manifesting a culture where employees across every level of health system feel empowered and know how they contribute to the mission and vision Creating a culture that embraces research and can nimbly incorporate evidence into practice

JH as a Learning Health System in the Era of Healthcare Transformation Interdependence Opportunity Advantage -Partnerships -Infrastructure -Culture shift JHHS care delivery side JHHC insurer JHU clinical researchers Research funding Embed research into clinical practice Access health system data Achieve patient- centered outcomes CMMI Award (JCHiP) Accountable Care Organization (JMAP) Maryland Health Services Cost Review Commission (HSCRC) Transformation Awards Research Grants PCORI, NIH, AHRQ

Challenges of Creating a Learning Health System Creating a mission and vision that are understood and embraced across every part of the health system Manifesting a culture where employees across every level of health system feel empowered and know how they contribute to the mission and vision Creating a system that embraces research and can nimbly incorporate evidence into practice

Challenges of Creating a Learning Health System Infrastructure and technology Communication Information sharing Rapid inclusion of evidence into practice Ensuring accountability