Learning Health System (LHS) Pillars Using Menear Model With Components Developed for Transitional Care Management (TCM) Quality Improvement Project in a Rural Primary Care System
| LHS Pillar | Elements | TCM Project Activities |
|---|---|---|
| Scientific | • Scientific expertise • Academic or research institutes, centers, and groups • Research training programs and knowledge-sharing activities • Research funding agencies and programs | • Use of best practice guidelines for
• Use of subject matter experts from The Dartmouth Institute for Health Policy and Clinical Practice • Dissemination of findings at local QI meetings and national publication |
| Social | • Multi-stakeholder networks and learning communities • Service or partnership agreements • Stakeholder engagement mechanisms (e.g., committees, advisory groups) | • Development of the Improvement Support Team (see Methods section) • In-person and virtual Learning Collaborative (see Methods section) |
| Technological | • Expertise in information technology and data science • Information technology systems • Health technologies or devices • Data infrastructures (e.g., electronic health records, clinical or administrative databases, clinical registry) • Communication technologies and platforms • Web or mobile applications • Data warehouses and marts • Interoperability frameworks | • Use of single EHR across all clinical sites • Uniform data entry for all key process indicators • Real-time data capture in clinic • EHR clinical decision support alerts to support key processes • Daily data extract from EHR into QI database • Data visualization using statistical process control (SPC) charts • Ability to filter SPC charts at multiple scales: provider, clinic, region, or system • Interoperability frameworks |
| Policy | • Governance and accountability structures and systems • LHS policies • LHS performance frameworks and incentive systems • Funding mechanisms for LHS operations and sustainability | • Creation of the Primary Care Service Line allowed for system-wide alignment and project prioritization. • Development, chartering, and funding of the Improvement Support Team • Organization involvement in risk-based contracts including Accountable Care Organizations drives need for reduced readmissions • PCP payment based on relative value unit payments is an incentive for TMC work • CMS payments for TMC and penalties for readmissions |
| Legal | • Privacy legislation • Laws governing healthcare institutions, organisations and professionals • Other laws, regulations and rules relevant to LHS activities | • Privacy legislation related to data use in healthcare (HIPAA, etc) • Healthcare system contracts with payers. |
| Ethical | • Ethics expertise • Ethical review boards and committees • Ethics guidelines, frameworks and rules | • Institutional Review Board determined that the TCM project was not human subjects research, making sharing of data much easier • Decision to make TCM services available to all patients regardless of location, medical conditions, insurance status, or other factors |