1. The Learning Healthcare System Starts with the VNA
Larry R. Sitka
The Office of the National Coordinator for Health Information Technology commonly referred
to as ONC released its initial draft of “ Connecting Health and Care for the Nation, A Shared
Nationwide Interoperability Roadmap DRAFT” framework document. Inside the 166 page
framework description ONC introduces the need for a platform called “A Learning Healthcare
System “, which the ONC defines as, “ an environment that links the care delivery system with
communities and societal supports in ‘closed loops’ of electronic health information flow, at
many different levels, to enable continuous learning and improved health.” The document is
designed to be a ten-year roadmap that describes barriers to interoperability across the current
health IT landscape. Within, is a description and proposal for a desired future state of
healthcare IT. Inside this document the ONC introduces an architecture overview for the next
10 years called The Learning Healthcare System and what is required of such a system.
In the report, the ONC states “by 2024, individuals, care providers, communities and
researchers should have an array of interoperable health IT products and services that support
continuous learning and improved health. This ‘learning health system’ should also result in
lower health care costs (by identifying and reducing waste and preventable events), improved
population health, empowered consumers and ongoing technological innovation through
coordinated care plans.
In the future, “Individuals, their families and health care providers should be able to send,
receive, find and use electronic health information in a manner that is appropriate, secure,

2. timely and reliable. Individuals should be able to securely share electronic health information
with care providers and make use of the electronic health information to support their own
health and wellness through informed, shared decision-making.”
While the vision and future state of the ONC is sound, we need to ask ourselves as healthcare
professionals, “Where do I begin? What can we do today to start reaping some of the benefits
of interoperability and provide us the foundation for the next ten years?” As with any
technology revolution, certain technologies mature faster than other and begin to drive the
landscape of the future. In the case of interoperability, vendor neutral archive (VNA) is that
mature technology that will lead in evolving the current healthcare ecosystem to a learning
healthcare system and providing a means for real time healthcare delivery. The foundation for
a Learning Healthcare System is the basis of what a Vendor Neutral Archive (VNA) provides
today. Leveraging and thinking of a VNA as just an imaging storage tool would be shortsighted,
why not think of a VNA as providing the pathway and functionality for a healthcare patient
centered discovery tool? VNA is the foundation of the Learning Healthcare System and a
foundation for building a healthcare IT interoperability framework whereby many applications
can work in unison learning the context of a patient, in-or-out of the current healthcare
organization. By leveraging a VNA in this context, a VNA provides suggestive results to the
healthcare organization’s user base. Leveraging a VNA is a means to improve patient outcomes
through interoperability and moves away from the traditional product sell. “Consumers are
increasingly expecting their electronic health data to be available when and where it matters to
them, just as their data is in other sectors. And new technology is allowing for a more
accessible, affordable and innovative approach. However, barriers remain to the seamless
sharing and use of electronic health information”, per the ONC architects.
A Foundation for a Learning Healthcare System starts with data ownership.
In the construction of a building, every project starts at the foundation. A foundation is critical
and must be well thought out with significant planning involved. The foundation is the most
difficult structure to change. The foundation of a Learning Healthcare System is built around
two key components, patient context and the healthcare organization (HCO) context. Taking
ownership of the data and focusing on interoperability across the HCO through standards are
pillars cemented into this foundation.
From the HCO perspective, ownership of clinical content on behalf of the patient is a
mandatory requirement. An assumed role inside the HCO, on behalf of the patient is the
holding of collected patient content for future use as a continuum of care for the patient. The
HCO must define and build a foundation by which secure sharing of patient content is inherent.
This environment must be capable of not just storing content, but also dynamically finding,
moving and distributing content in real time. This content is linked and possibly moved into a
Learning Healthcare System independent of the organizations affiliation. The content is either

3. linked on demand or linked covertly as the information is discovered further extending the
patient longitudinal record. The goal of content aggregation is to provide suggestive access to
patient information for the healthcare worker who is responsible for delivering that better
patient outcome. The patient outcome is the evidence by which the HCO shall be paid.
From the patient perspective, ownership of the data by the patient is now something we, as
vendors must enable and HCO providers are legally bound to steward. HIPAA for example,
appears to vendors as restricting and controlling. It attempts to define who and what content
can be accessed along with the purpose of accessing that content. However, it is actually HIPAA
that finally gives ownership of the content back to the patient. It’s the first piece of legislation
actually directing the HCO and its vendors true ownership of results and supporting
documentation belongs to the patient and not the healthcare organization, insurance
companies, or the product vendors.
Framing a Learning Healthcare System through the use of standards and blueprints
Once the foundation of a Learning Healthcare System is created the framing is next. Framing
comes with exact measurements and sizing using standards based products, but with the
cutting and coercion of the materials comes a custom fit per the requirements in a blue print.
Such is the case of a Learning Healthcare System. The HCO, in effort to create a Learning
Healthcare System, must start by demanding standardization of not only structured content but
unstructured content. Standardization not only to assure interoperability, but standardization
as a canonical data model based on industry standards and not proprietary vendor specifics.
Standardization or canonicalization of the meta-data to be used and exchanged in a Learning
Healthcare System is exactly what a true VNA platform provides. Simple problems come with
very complex solutions in these cases. For example, patient names, IDs or study descriptions
have become as complex to the HCO as the year 2000 problem. Imagine an IT infrastructure
without being based on wireless or Ethernet standards for physical connectivity, what chaos
would exists. Simply put what if we all drove down an interstate without those painted lines
and the map we used to guide us didn’t have a legend in place. Such is the case for the HCO
when it comes to delivering a standards based form of patient content. The DICOM and HL7
standards exists and we have the XDS framework, but without the connect-a-thons and HCO
demanding that vendors not only participate in these but also demand the vendors actually
support and utilize those standards. More importantly the HCO must contractually demand
interoperability following those exact standards. In short HCOs must stop purchasing custom
solutions unique to only its organization.
The deployment of the EMR to capture and attempt to hold unstructured content at least
inside a data warehouse application is a step in the right direction. Unfortunately the EMR only
solves half the problem by providing a collection point. As a next step try and share the

4. unstructured content between EMRs and between organizations. This has become a next to an
impossible task. Those EMRs that claim to be able to share come up far short of expectations.
The idea of sharing an electronic record is what drove EMR adoption. Now we have all this
unstructured content that must feed the Learning Healthcare System. The VNA is capable and
is the platform for doing so.
Adding the roof, connecting the plumbing and utilities to a Learning Healthcare System by
allowing a multi-vendor best of breed solution.
The final steps in a construction process are completed by picking the best products with the
best look and feel meeting the needs of the owner. Such is the case of a Learning Healthcare
System. A Learning Healthcare System demands the ability to select the best products with the
best functionality that delivers the best patient outcomes. Different departments and
healthcare settings, much like different physicians, have different needs and requirements.
Why be limited with just one selection? More importantly don’t be forced into a one size fits all
in selection of applications. Let the HCO users pick their applications to deliver better patient
outcomes. For example a radiology centric viewer does not work for wound care or treatment
planning very efficiently.
When connecting the building to the outside world each location typically has its own utilities
companies which are part of a grid. The same is true for a Learning Healthcare System. The
existing Healthcare Information Exchanges (HIE’s) are the on-ramps for the Learning Healthcare
System. The HIE and image or content exchange will evolve into much more than we know
today. Today HIEs are not profitable and even more difficulties arise when seeking cooperation

5. amongst the different unaffiliated organizations for patient informational access. Vendors of
course find it difficult to build any product today around what isn’t profitable and a very hard to
sell to HCO executive teams. However, tomorrow HIE technology inside the Learning
Healthcare System will not only be the necessity but be integral parts of any HCO, thus make
sure image and content exchange is included in your VNA as an embedded feature. Sharing
the patient content across the private sector, across HIEs, and across government organizations
will be common place in the next decade all driven by patient outcomes. Today these HIE are
laying the ground work for what is required not only from the technology perspective but more
importantly the business and legal perspective. The VNA selected should support an HIE
inherently. An image/content exchange is mandatory requirement of a VNA and is the basis of
a Learning Healthcare System for moving released content in a secure manner. More
importantly inside a Learning Healthcare System an image/content exchange must provide the
business process and verification steps. Steps like BAA approval and appropriate patient
release form access and approval are automated.
Turing on the power and utilities inside a Learning Healthcare System and let the information
flow.
The data demands of a Learning Healthcare System will far exceed anything an HCO has seen to
date. Typically the sizing of a VNA is done by traffic volumes requested by concurrent users or
study volumes. However the oncoming big data analytics applications which are a necessity
inside a Learning Healthcare System will far exceed any current traffic volumes requested by
mere humans. A Learning Healthcare System is in a mode of continuously finding, aggregating,
and coercing information relevant to the patient in context, again a necessity to building out
the patient record. Once found, the information is persisted in the Learning Healthcare System
whereby the analytics and other applications such as Natural Language Processing (NLP)
systems will access the information giving the data context around the patient allowing the
healthcare worker better informational access and decision process through new clinical
support applications. Support for these demanding applications require an infrastructure that
can scale on demand both horizontally and vertically. Leverage your VNA for more than just
basement storage where things become cluttered and inefficient while never being used again.
Conclusion The Smart House is a Learning Healthcare System all built on a VNA platform.
The Learning Healthcare System will be an integral part of improving the way the healthcare
ecosystem works and how patients, providers and payers interact within that ecosystem. It will
be a gradual process to achieve the complete vision of the Learning Healthcare Systems and
lessons will be learned along the journey. However, there are things that we can do today to
begin to build the necessary foundation for this vision. Adoption of VNA technology is one of

6. these cornerstones that is mature enough today to begin to solve some of the greatest
challenges and remove some of the obstacles to a fully interoperable healthcare system.