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DeWaters AL, Miller EL, Haidet P, Gonzalo JD. Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:424-429. [PMID: 37881916 DOI: 10.1097/acm.0000000000005478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
PURPOSE Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it and to use those findings to inform the current SBP construct. METHOD Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. RESULTS Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. CONCLUSIONS Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.
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Smith CL, Fisher G, Dharmayani PNA, Wijekulasuriya S, Ellis LA, Spanos S, Dammery G, Zurynski Y, Braithwaite J. Progress with the Learning Health System 2.0: a rapid review of Learning Health Systems' responses to pandemics and climate change. BMC Med 2024; 22:131. [PMID: 38519952 PMCID: PMC10960489 DOI: 10.1186/s12916-024-03345-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/23/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Pandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0. METHODS Three databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS's response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite's LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance. RESULTS The search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges. CONCLUSIONS An LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events. TRIAL REGISTRATION PROSPERO pre-registration: CRD42023408896.
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Affiliation(s)
- Carolynn L Smith
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia.
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia.
| | - Georgia Fisher
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Putu Novi Arfirsta Dharmayani
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Shalini Wijekulasuriya
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Samantha Spanos
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Genevieve Dammery
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, 75 Talavera Road, North Ryde 2113, Sydney, Australia
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Hewitt AM. The Coproduction of Health Framework: Seeking Instructive Management Models and Theories. Adv Health Care Manag 2024; 22:181-210. [PMID: 38262016 DOI: 10.1108/s1474-823120240000022009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.
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DAWES DANIEL, GONZALEZ JUAN. The Politics of Population Health. Milbank Q 2023; 101:224-241. [PMID: 37096618 PMCID: PMC10126954 DOI: 10.1111/1468-0009.12603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/18/2022] [Accepted: 01/06/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Despite increased spending and consuming more health care services than any other country in the world, the United States global health rankings experience continued decline, including worsening performance in life expectancy and mortality owing to lack of investment in and strategies on the upstream determinants of health. These determinants of health are found in our access to adequate, affordable, and nutritious food options; safe housing, blue and green spaces; reliable and safe transportation; education and literacy; opportunities for economic stability; and sanitation, among other important factors and all share a common root driver in the political determinants of health. Health systems are increasingly investing in programs and exerting influence over policies to address these upstream determinants of health, including population health management, however these programs will continue to be hindered without addressing the political determinants through government, voting, and policy. Although these investments are laudable, it is important to understand what gives rise to the social determinants of health and-more importantly-why have they disproportionately and detrimentally affected historically marginalized communities and vulnerable populations for so long? Deeply entrenched and pervasive throughout society, the political determinants of health are the fundamental instigators of these unjust and inequitable outcomes.
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Affiliation(s)
- DANIEL DAWES
- Meharry Medical College Ringgold Standard InstitutionInstitute of Global Health Equity
| | - JUAN GONZALEZ
- Meharry Medical College Ringgold Standard InstitutionInstitute of Global Health Equity
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Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC FAMILY PRACTICE 2021; 22:237. [PMID: 34823495 PMCID: PMC8614080 DOI: 10.1186/s12875-021-01589-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations. METHODS We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study. RESULTS Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time. CONCLUSION Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.
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Affiliation(s)
- Stephanie L Albert
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA.
| | - Margaret M Paul
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA
| | - Ann M Nguyen
- Center for State Health Policy, Rutgers, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Donna R Shelley
- Global Center for Implementation Science, Department of Policy and Public Health Management, New York University School of Global Public Health, 665 Broadway, 8th Floor, New York, NY, 10012, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA
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Ahuja M, Aseltine R. Barriers to Dissemination of Local Health Data Faced by US State Agencies: Survey Study of Behavioral Risk Factor Surveillance System Coordinators. J Med Internet Res 2021; 23:e16750. [PMID: 34255650 PMCID: PMC8317038 DOI: 10.2196/16750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/19/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Advances in information technology have paved the way to facilitate accessibility to population-level health data through web-based data query systems (WDQSs). Despite these advances in technology, US state agencies face many challenges related to the dissemination of their local health data. It is essential for the public to have access to high-quality data that are easy to interpret, reliable, and trusted. These challenges have been at the forefront throughout the COVID-19 pandemic. Objective The purpose of this study is to identify the most significant challenges faced by state agencies, from the perspective of the Behavioral Risk Factor Surveillance System (BRFSS) coordinator from each state, and to assess if the coordinators from states with a WDQS perceive these challenges differently. Methods We surveyed BRFSS coordinators (N=43) across all 50 US states and the District of Columbia. We surveyed the participants about contextual factors and asked them to rate system aspects and challenges they faced with their health data system on a Likert scale. We used two-sample t tests to compare the means of the ratings by participants from states with and without a WDQS. Results Overall, 41/43 states (95%) make health data available over the internet, while 65% (28/43) employ a WDQS. States with a WDQS reported greater challenges (P=.01) related to the cost of hardware and software (mean score 3.44/4, 95% CI 3.09-3.78) than states without a WDQS (mean score 2.63/4, 95% CI 2.25-3.00). The system aspect of standardization of vocabulary scored more favorably (P=.01) in states with a WDQS (mean score 3.32/5, 95% CI 2.94-3.69) than in states without a WDQS (mean score 2.85/5, 95% CI 2.47-3.22). Conclusions Securing of adequate resources and commitment to standardization are vital in the dissemination of local-level health data. Factors such as receiving data in a timely manner, privacy, and political opposition are less significant barriers than anticipated.
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Affiliation(s)
- Manik Ahuja
- Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN, United States
| | - Robert Aseltine
- Center for Population Health, UConn Health, Farmington, CT, United States
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