1. The Community As A Learning Health System Larry A. Green, MD University of Colorado Denver September 20, 2012

2. May 2012

4. 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.

5. Reasons Americans Die Prematurely 5 McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.  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

6. A Primary Care Perspective: The 2000 Ecology. Green et al NEJM 2001

7. 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

8. 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: 28% regional 29% state 28% local 15% national Network type: 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

9. 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 9 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

10. One View of Critical Passages From what –to—what?

12. wHealthcare Healthcare Commercialism Professionalism Profit Healthy Communities Technicians/Lineworkers Personal Physicians More! Enough! Volume! Value! Produce Inequities Relieve Disparitites

13. Fragmentation Integration Shrinking Scope Comprehensive Scope PH+MH+PC+FM Reunited-Integrated Platform Biologic Science All Relevant Science Little Data Big Data Fuzzy Boundaries Multilateral Compacts Pay for Fragments Blended/Bundled Payment

14. Chess Jigsaw Puzzle Heroic Physician Championship Team Weak Infrastructure New Infrastructure Passive Recipients Voracious Explorers Randomizing Confounders Using Confounders

15. Shaping a Health Statistics Vision for the 21 st Century (2002) 15

16. 16 Pharmaceutical Firm Beacon Community Integrated Delivery System Community Practice Health Information Organization Health Center Network Federal Agencies State Public Health Governance Engagement Standards Trust Analysis Dissemination 16 A Learning Health System

17. Health Data Stewardship: What, Why, Who, How-- An NCVHS Primer (2009) 17

18. Published, November 2011 Joint Project of the Population Health and Privacy, Security and Confidentiality Subcommittees

19. Health is a Community Affai r “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

20. S UCCESS F ACTORS IN C OMMUNITY L EARNING S YSTEMS FOR H EALTH 1.A galvanizing health concern. 2.A comprehensive understanding of health and community health. 3.Collaborative culture; social capital. 4.Trust and community engagement. 5.Access to data on local health and its determinants, plus analytic capacities. 6.Data display and dissemination capacities. 7.Functioning coalitions, community engagement, agreement on priorities. 8.Organizational and technical support. 9.Political and financial support. 10.Processes and systems to translate information and priorities into action, evaluate results, and modify as needed. 20

21. Institute of Medicine March 28, 2012 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

22. 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

23. 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.

26. 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.

27. 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.

29. Thank You--for Being You and Doing What YOU Do!