Pub Date: Thursday, Dec 03, 2020
Author: Thomas E. Kottke, MD, MSPH, FAHA, FACC
Affiliation: HealthPartners, Minneapolis, Minnesota
In response to the American Heart Association (AHA) 2030 impact goal,1 the AHA Scientific Statement, Achieving Optimal Population Cardiovascular Health Toward the 2030 Goals Requires an Interdisciplinary Team and a Learning Healthcare System,2 advocates a vision of interdisciplinary teams comprising epidemiologists, biostatisticians, implementation scientists, clinicians, and more than half a dozen other specialists forming the driving force of learning healthcare systems (LHS). As described,2 the teams would generate data, test hypotheses, and transform information into knowledge for the healthcare system to use as it promotes primordial prevention (the prevention of risk factors) and primary prevention (the treatment of risk factors that have developed). In a continuous cycle of process improvement, the impact of the intervention would be assessed and fed back to the learning team for refinement and subsequent deployment in the clinic or the community.
The comprehensive approach that includes primordial and primary prevention greatly increases the odds that the AHA 2030 impact goal of increasing life expectancy by two years will be reached. While improving care for acute cardiovascular events might prevent or postpone about 8% of all deaths in the American population aged 30-84, adoption of primordial and primary prevention opportunities similar to the AHA’s Life’s Simple 73 could prevent or postpone up to one-third of all deaths.4 The large impact of primordial and primary prevention is due to the fact that reducing risk of death from cardiovascular disease (CVD) and stroke by addressing the Simple 7 also reduces risk of death from conditions that include cancer, diabetes, renal disease, and lower respiratory diseases, among others.5
The AHA statement that promotes interdisciplinary teams and a learning healthcare system2 offers the SPHERE trial and Priorities Wizard as evidence that the interdisciplinary learning team concept can be effective.6, 7 Priorities Wizard, for example, extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the clinical decision support output seamlessly on the EHR screen for use by the clinician and patient. It does all of this in real time while the patient is being readied for their visit. Cluster-randomized trials show that this approach to clinical decision support system can significantly improve glucose and blood pressure control in diabetes patients, reduce 10-year cardiovascular risk in high risk adults without diabetes, improve management of smoking in dental patients, and improve high blood pressure identification and management in adolescents.7, 8 Clinicians in several large group practices now have access to Priorities Wizard and report that they are highly satisfied with the tool.
But this doesn’t mean that the interdisciplinary learning team has finished its work. Even though the potential benefit of clinical decision support is great, tools like SPHERE or Priorities Wizard must surmount a significant hurdle before they become standards of medical practice. While matters of scale make it possible for large group practices like Geisinger Health System and Kaiser Permanente to sponsor interdisciplinary learning teams and adopt innovations like SPHERE and Priorities Wizard,9, 10 12% of American physicians practice solo and more than half practice in groups of 10 or fewer.11 Because solo and small group practices tend to lack the personnel and financial resources that are necessary to access their own electronic health record data for quality improvement or prospective patient management,12, 13 there is little reason to believe that they will be able to maintain sophisticated clinical decision support programs without the ongoing support that would allow them to access interdisciplinary teams.
There are solutions that could be brought to scale. OCHIN, a non-profit that supports over 500 clinical organizations, is one.14 Likewise, the recent EvidenceNOW trial, sponsored by AHRQ, provides several different models, but it also illustrates the challenges that must be overcome if small primary care practices are to have access to sophisticated clinical decision support.15
Thinking beyond the clinical encounter, workforce health promotion is an opportunity for interdisciplinary learning teams to promote the AHA 2030 impact goal within their own organizations.16, 17 More than 15 million Americans are employed in health care,18 and their family members number an additional 25 million.19 All could potentially be reached through employment-based health and well-being programs. Because leadership may need to be convinced that the programs have value20 and the healthcare workforce is culturally diverse, the team should be open to input by economists, anthropologists, and the end users as they explore which interventions and which team members add value and which do not. What they find will depend on the question being asked and the local context.
Another non-clinical situation in which interdisciplinary learning teams should be engaged is in the development of health promotion messaging. For example, an interdisciplinary team at HealthPartners first used qualitative and quantitative methods to gather feedback from the end user and then used social media to test 11 different messages that might be used in a health education campaign designed to increase awareness about safe fish consumption.21 In a controlled trial, they were able to rapidly identify clear preferences in 9 of 10 comparisons. They also found evidence that more women prefer the presentation of information as questions rather than narratives, marketing rather than patient education, and uncertain rather than certain copy. They also found that pregnant women were more likely to prefer a message from experts while nonpregnant women preferred a message from physicians. None of this would have been known without an interdisciplinary team taking a learning system approach.
While the learning healthcare system, as originally conceptualized, focused exclusively on the clinical setting,22 the focus of AHA 2030 impact goal on health and well-being with equity creates both an opportunity and an obligation for interdisciplinary learning teams to develop solutions beyond the walls of healthcare. The opportunity is the development of new methods of learning in partnership with communities. The obligation is to explore community environments because the community is a powerful determinant of whether a population is healthy or burdened with chronic diseases.23, 24 Interdisciplinary teams will also need to engage across the lifespan because risk of CVD begins in utero25, 26 and the experience of children in their earliest years is critical for their development throughout the life course.27 The most effective teams will examine multiple settings, use mixed methods, and consider broad contextual factors. They will view their learnings from multiple angles and perspectives so as to avoid unintended consequences and leverage systems characteristics such as, for example, benefits designs and legal/policy factors.
Kaiser Permanente has used community-oriented interdisciplinary teams in its learning healthcare organization to develop and guide Thrive Local, its network program that addresses a broad range of social needs.28 Collaborating with Unite Us, Kaiser Permanente is able to refer patients with social needs to community based organizations and receive feedback about whether a contact was made, whether a social need was addressed, and whether a social need was met. The interdisciplinary learning teams use this information to improve their system and create new solutions as necessary. In 2015, Tyler Norris, formerly at Kaiser Permanente and one of the authors of the AHA 2030 impact goal offered examples of how a selection of other healthcare organizations are making a difference by improving housing, promoting economic development, and promoting collaboration around community safety, food access, and educational opportunity with community-based organizations.29 Health care organizations can have an impact that is larger than their community benefit budgets, by developing interventions that create shared value rather than relying on their philanthropic resources.30
For interdisciplinary healthcare learning teams to contribute at the highest level, researchers and operational workers will need to respect each other and collaborate—something that may not occur if either party fails to understand that the other’s needs and exigencies differ from their own. While researchers have the apparent luxury of long timelines with which to pursue lines of investigation that they themselves have selected, they are obligated to carefully craft disconfirmable hypotheses, garner financial support, and conduct a trial. This creates a situation in which a question may be answered only years after it is posed. By contrast, operational workers have little opportunity to choose the challenges they face, but they only need to create a solution that is acceptable to the end-user. These differences can lead those in operations to view researchers as slow, hypercritical and unhelpful. In return, researchers can view operational workers as lacking rigor. Neither belief is necessarily true, and leaders may need to repeatedly emphasize that all parties are contributing to personal and population health and well-being; they simply contribute at different points on the continuum from knowledge development to implementation.31 A solution developed by HealthPartners is the organization of a unit that comprises the analytic skills of a research organization while being dedicated to meeting the evaluation needs of operational units in a timely fashion.32
Modern science shows that hearts, bodies, and minds are interconnected and are best able to thrive in a world designed for health and well-being in the broadest sense. Such a world ensures that vital conditions needed to create health and well-being are present for everyone, including societal and structural contributors to health such as housing, education, safety, access to healthy food, meaningful and sufficiently paid work, and clean air and water, as well as healthy environments…Efforts to save lives and to prevent premature deaths and disability are thus combined with those aimed at expanding prosperity, a sense of connection and purpose, and other conditions that enhance the experience and productivity of life.1
These words from the AHA Impact Goal statement define a global health and well-being agenda for the next decade. Interdisciplinary teams, using their ingenuity, skills, and synergism, will achieve it.
Foraker RE, Benziger CP, DeBarmore BM, Cené CW, Loustalot F, Khan Y, Anderson CAM, Roger VL; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Lifestyle and Cardiometabolic Health. Achieving optimal population cardiovascular health requires an interdisciplinary team and a learning healthcare system: a scientific statement from the American Heart Association [published online ahead of print December 3, 2020]. Circulation. doi: 10.1161/CIR.0000000000000913.
- Angell SY, McConnell MV, Anderson CAM, Bibbins-Domingo K, Boyle DS, Capewell S, Ezzati M, de Ferranti S, Gaskin DJ, Goetzel RZ, Huffman MD, Jones M, Khan YM, Kim S, Kumanyika SK, McCray AT, Merritt RK, Milstein B, Mozaffarian D, Norris T, Roth GA, Sacco RL, Saucedo JF, Shay CM, Siedzik D, Saha S and Warner JJ. The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association. Circulation. 2020;141:e120-e138.
- Foraker RE, Benziger CP, DeBarmore BM, Cené CW, Loustalot F, Khan Y, Anderson CAM, Roger VL; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Lifestyle and Cardiometabolic Health. Achieving optimal population cardiovascular health requires an interdisciplinary team and a learning healthcare system: a scientific statement from the American Heart Association [published online ahead of print December 3, 2020]. Circulation. doi: 10.1161/CIR.0000000000000913.
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- Kottke TE, Faith DA, Jordan CO, Pronk NP, Thomas RJ and Capewell S. The comparative effectiveness of heart disease prevention and treatment strategies. Am J Prev Med. 2009;36:82-88 e5.
- Ogunmoroti O, Allen NB, Cushman M, Michos ED, Rundek T, Rana JS, Blankstein R, Blumenthal RS, Blaha MJ, Veledar E and Nasir K. Association Between Life's Simple 7 and Noncardiovascular Disease: The Multi‐Ethnic Study of Atherosclerosis. Journal of the American Heart Association. 2016;5.
- Foraker RE, Shoben AB, Kelley MM, Lai AM, Lopetegui MA, Jackson RD, Langan MA and Payne PR. Electronic health record-based assessment of cardiovascular health: The stroke prevention in healthcare delivery environments (SPHERE) study. Prev Med Rep. 2016;4:303-8.
- Sperl-Hillen JM, Rossom RC, Kharbanda EO, Gold R, Geissal ED, Elliott TE, Desai JR, Rindal DB, Saman DM, Waring SC, Margolis KL and O'Connor PJ. Priorities Wizard: Multisite Web-Based Primary Care Clinical Decision Support Improved Chronic Care Outcomes with High Use Rates and High Clinician Satisfaction Rates. EGEMS (Wash DC). 2019;7:9.
- Sperl-Hillen JM, Crain AL, Margolis KL, Ekstrom HL, Appana D, Amundson G, Sharma R, Desai JR and O'Connor PJ. Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial. J Am Med Inform Assoc. 2018;25:1137-1146.
- Paulus RA, Davis K and Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27:1235-45.
- Greene SM, Reid RJ and Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157:207-10.
- Henry TA. Employed physicians now exceed those who own their practices. 2019;2020.
- Cohen DJ, Dorr DA, Knierim K, DuBard CA, Hemler JR, Hall JD, Marino M, Solberg LI, McConnell KJ, Nichols LM, Nease DE, Edwards ST, Wu WY, Pham-Singer H, Kho AN, Phillips Jr RL, Rasmussen LV, Duffy FD and Balasubramanian BA. Primary Care Practices’ Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement. Health Affairs. 2018;37:635-643.
- Dorr DA, Cohen DJ and Adler-Milstein J. Data-Driven Diffusion Of Innovations: Successes And Challenges In 3 Large-Scale Innovative Delivery Models. Health Aff (Millwood). 2018;37:257-265.
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- EvidenceNOW Publications. 2019;2020.
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