1. Reproduced with permission from Health IT Law & In-
dustry Report, 2 HITR 23, 06/04/2010. Copyright ஽
2010 by The Bureau of National Affairs, Inc. (800-372-
1033) http://www.bna.com
Accelerating Health Care Value: Innovating Our Way Toward a Learning Health
System
‘‘Readiness for change is one of the hardest problems we face,’’ Paul Tang, HIT Policy
Committee vice chair and Palo Alto Medical Foundation vice president and chief medical
information officer.
‘‘To realize our vision, we must foster a pervasive culture of innovation,’’ Douglas D.
French, former Ascension Health president and chief executive officer.
BY RICHARD SINGERMAN, PH.D. Overview
T
he U.S. Department of Health and Human Services
Office of the National Coordinator for Health In-
formation Technology (ONC) articulates a long
term strategy that envisions the U.S. Health System
transforming into a Learning Health System (LHS).
What does LHS mean for individual consumers and cli-
nicians that strive for vibrant lives? What does LHS
mean for the organizations through which consumers
and clinicians interact? What is the interplay between
consumers, clinicians and these organizations? In this
first in a series of articles on how health care innovation
can accelerate health care value, we lay out a simplified
view of an LHS, an organizational innovation process to
transform over time to an LHS, and the corresponding
consumer and clinician individual innovation required
to achieve the associated LHS organizational innova-
tion.
Richard Singerman, Ph.D., is a health care
innovation and informatics consultant and
public speaker. He is also a member of
the Advisory Board for BNA’s Health IT &
Law Industry Report. Dr. Singerman has
served in innovation leadership and advisory
roles for hospital systems, research institu-
tions and government organizations. He has a
particular emphasis on mission-driven health
organizations such as Catholic health sys-
tems, children’s hospitals and the U.S. Mili-
tary Health System. His vision is of a perva-
sive culture of innovation for health
consumers, clinicians and health care organi-
zations. He may be reached at
richardsingerman2@gmail.com
REPORT
COPYRIGHT ஽ 2010 BY THE BUREAU OF NATIONAL AFFAIRS, INC. ISSN 2151-2876
A BNA, INC.
HEALTH IT!
LAW&INDUSTRY

2. Approach
In this series, we take a hybrid approach leveraging
Organizational Learning concepts (Peter Senge et al.),
Organizational Innovation concepts (James Quinn et
al.), Disruptive Innovation concepts (Clayton Christen-
son et al.), reports and round tables from the Institute
of Medicine, federal advisory bodies and public hear-
ings for the HHS ONC, professional experiences from
serving in innovation and knowledge sharing leader-
ship and/or advisory roles for some of the largest mis-
sion driven health systems in the world, and personal
experiences in managing the health of a cancer survivor
and the health of someone who just plain got old.
Learning Health System Target Outputs
Per the Institute of Medicine, ‘‘A learning health sys-
tem is a system that is designed to generate and apply
the best evidence for the collaborative health care
choices of each patient and provider; to drive the pro-
cess of new discovery as a natural outgrowth of patient
care; and to ensure innovation, quality, safety, and
value in health care.’’ We interpret this definition visu-
ally as a triangle (shown in Figure 1) composed of Qual-
ity, Community and Value targets at the corners and an
Innovation Engine in the middle to drive progress to-
wards the targets. The Quality target is focused around
the Institute of Medicine aims of care being safe, effec-
tive, patient-centered, timely, efficient and equitable.
The Community target is focused on research and de-
velopment, public health protection, social networks,
social services leverage and new market entrant facili-
tation. The Value target is focused around individual
quality of life, population-based outcomes, transpar-
ency, cost over time, incentives and return on invest-
ment.
Learning Health System Innovation Engine Driving
Target Outputs
By ‘‘innovation,’’ we mean a value-added solution to
a problem. Innovation can take place at the organiza-
tional level or individual level. In either case, we break
down the Innovation Engine into six key components:
scanning, sharing, incubating, partnering, measuring,
and aligning innovations. These Innovation Engine
components (shown in Figure 2) are defined as follows:
s Scanning is creating the two to 10 year vision of
the health system integrating perspectives on ar-
eas such as consumerism, clinical technology, in-
formation technology, policy, economics (reim-
bursement and access to capital among other is-
sues), clinician relations, health care labor
shortages, environmental health and organiza-
tional mission. Scanning is also about understand-
ing what others are doing that is successful today
and how that success can be spread
s Sharing is the multichannel communication pro-
gram for the knowledge obtained from scanning.
At the organizational level, this communication
ranges from in person innovation sharing sessions
and innovation road shows to an online exchange
similar to an eBay of health innovations. At the
consumer level, this sharing could occur through
clinician to consumer relationships or through
highly disruptive channels such as Patients-
LikeMe (in which consumers openly share health
information with each other in an online forum
that facilitates aggregation of information across
patient populations with the intent of accelerating
disease cures for these populations).
s Incubating is trying the innovation tailored to in-
dividual and/or organizational needs.
s Partnering is bringing in the capabilities and as-
sets (that the individual and/or organization does
not yet have access to) needed to incubate the in-
novation.
s Measuring is quantifying the impact of the innova-
tion.
Figure 1: Consumers, clinicians and the Health System as a whole each have goals around
Quality, Community and Value. Each has an Innovation Engine, detailed in Figure 2, to reach
these goals.
QUALITY
Innovation
Engine
VALUE COMMUNITY
Figure 2: The Innovation Engine for consumers, clinicians and the Health System as a whole
has 6 key components: Scanning, Sharing, Incubating, Partnering, Measuring and Aligning
Innovations.
Aligning Scanning
SharingMeasuring Innovation
Engine
Innovation
Engine
Partnering Incubating
Figure 3: In the Learning Health System, knowledge intensive assets are converted into
Quality, Community and Value target outputs. In particular, the Innovation Engine (detailed
in figure 2) is fueled by People, Process, Technology and Relationship Capital in addition tog ) y p , , gy p p
Fiscal Capital.
Technology Process
People
Relationships
Innovation
Quality
Engine
CommunityValue
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3. s Aligning is ensuring that individuals and/or orga-
nizations are incentivized to adopt value creating
innovations.
Learning Health System Inputs: Fuel for the
Innovation Engine
In short, the Innovation Engine for consumers, clini-
cians and the Health System as a whole uses knowledge
intensive inputs to create Quality, Community and
Value outputs (shown in Figure 3). The Innovation En-
gine is fueled by a mix of knowledge intensive capital
and fiscal capital. These knowledge intensive capital as-
sets include People, Processes, Technology and Rela-
tionships and are defined as follows:
s People Capital includes what are in the heads and
hearts of individuals. This includes individual’s
collective skills, motivations, professional commu-
nities they aggregate in, and their ability to con-
tinuously learn.
s Process Capital includes institutional organization
and know-how. This includes governance (who
makes decisions and how are they made), policies,
best practices, patents, trade secrets and proce-
dures that channel people’s collective skills into
value creation.
s Technology Capital includes the tools, databases,
and infrastructures that people use in their pro-
cesses. In health care, this includes clinical tech-
nology and information technology (ranging from
user applications, to the underlying data to the
supporting computers and networks to securely
acquire, store, analyze and distribute informa-
tion).
s Relationship Capital essentially comes down to
trust. It is what others think of you as a consumer,
clinician or organization. For an organization, it
includes partners and customers.
Putting It All Together: Interplay between
Consumers, Clinicians and the Health System to
form a Learning Health System
Next, we connect how consumers and clinicians
should view themselves as the key players in the LHS
(shown in Figure 4). Abstracting from Organizational
Learning concepts, consumers and clinicians each have
a personal learning triangle that defines their targets
and how they innovate towards them. Consumers and
clinicians each have targets around Quality, Commu-
nity and Value. Each has an Innovation Engine to drive
toward the targets. In particular, consumers and clini-
cians drive their own Innovation Engines on the indi-
vidual level to foster innovation on the LHS organiza-
tional level. For example, a clinician pursuing Quality
may focus on safety and effectiveness. A consumer fo-
cusing on Quality may focus on hospital outcomes.
Continuing the Organizational Learning point of
view, the consumer, clinician and Health System tri-
angles interact. The consumer, clinician and Health
System taken together form a deceptively simple look-
ing machine that converts knowledge intensive assets
(People, Process, Technology and Relationships) into
Quality, Community and Value via simultaneously run-
ning Innovation Engines. This is the full picture of what
we mean by the Learning Health System (shown in Fig-
ure 5).
Learning Health System Key Implications
While the LHS depicted as an innovation driven ma-
chine may look simple, from an Organizational Learn-
ing point of view the implications of the LHS are any-
thing but simple. In particular the implications are as
follows:
1. Reaffirm Key Trust Relationship: Across the
myriad of relationships within the LHS, the consumer
to clinician relationship (or network connection) is
paramount. This is among the prime relationships from
which trust emanates. Yet, this fundamental relation-
ship has frayed over the past decade. Further, as tens of
millions of Americans gain new levels of access (via in-
surance coverage) to the currently ‘‘broken’’ US Health
Care System, it is not at all clear who will be the clini-
cians that serve these new customers and how their
trust will be earned.
Consider an Alternative Trust Paradigm and Its Im-
plications for Health Reform: Will the newly insured
become a bolus moving through the Health System that
simply cannot be absorbed through traditional health
channels? Will trust no longer be based on the bond be-
tween a lead clinician and the consumer? Will trust be-
come distributed among multiple sources from (a) time
pressed primary care providers to (b) nurse practitio-
ners at retail clinics (such as those at CVS and
Walmart) to (c) direct-to-consumer pharmaceutical ad-
vertisements to (d) to remotely accessed second opin-
ions and teleconsults from halfway around the world. If
so, then the hopes for new models of care such as the
Medical Home (in which a particular clinician can
Consumer
QualityQuality
C itV l
I
CommunityValue
QualityQuality Mutual
Learning
II
Clinician
CommunityValue
Health System
CommunityValue
Figure 4: In the Learning Health System, consumers, clinicians and the Health System each
have their respective target outputs for Quality, Community and Value. Each drives an
Innovation Engine towards their respective targets. All the while, the consumer and
clinician mutually learn from each other (purple arrows) as well as enabling overall Health
System learning (purple arrows).
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4. qualify for additional reimbursement for taking the lead
on care coordination) may not be fully realized.
2. Overcome Limits to Health System Performance:
For the LHS to run smoothly, the rate of change for the
LHS is explicitly dependent on the rate of change for
consumers and clinicians. In particular the LHS cannot
run asynchronously with care models and policies flow-
ing from the health system that are out of synch with
the readiness of consumers and clinicians to interact
with and adopt those care models and policies.
Recognize Need for Nudging1
: Adapting from Rich-
ard Thaler’s and Cass Sunstein’s Nudge, we may be so
overrun with information, that it is not a bad thing to
have defaults set that ‘‘nudge’’ in the direction of better
health behaviors. Yes, we as consumers do need to be
more accountable than we are today for our aggregate
societal health status, but it doesn’t hurt when office
building stairwells are painted brighter and carpeted so
that we feel more comfortable (or perhaps have fewer
excuses) so that we take the steps rather than the eleva-
tor.
Give Permission for Noodging2
: In contrast to the
nudging of consumers (for whom New Year’s resolu-
tions sometimes fade into forgotten personal objec-
tives), people in well run health organizations have
clear organizational objectives with annual accountabil-
ity. As part of the organizational process to reach objec-
tives, there may be members of an organization
charged with helping others explicitly reach objectives.
These helpers have permission to noodge (an especially
useful activity in decentralized organizations where
strategic goals can sometimes go to the back burner as
pressing operational issues arise). Creating a Learning
Health System, however, is a long term process. To
smooth the way there, consumers will sometimes have
to be nudged while an organization’s people will some-
times have to be noodged on the way to reaching their
long term targets.
3. Foster Culture of Innovation: Overall the success-
ful interplay between consumers, clinicians and the
Health System requires innovation at the individual and
organizational levels. Broadly speaking, to be success-
ful as a nation in achieving the LHS vision, and ulti-
mately accelerating health care value, we need (in the
words of the former CEO of Ascension Health) to ‘‘fos-
ter a pervasive culture of innovation’’ - a personal ac-
countability toward pushing ourselves as consumers or
clinicians to ‘‘raise the bar.’’ Each consumer, each clini-
cian and each health organization must scan, share and
incubate innovations. Government may have recently
set a platform for Health System change, but let us not
expect Government to make the change for us.
Case Study on Achieving Clinical Quality
Improvement and Organizational Performance
Improvement: Implementing Organizational
and IT-Enabled Innovation at Intermountain
Health Care
Situation
XYZ Health System wants to become a Learning Or-
ganization. Many knowledge intensive assets are com-
mon to Intermountain Health Care and XYZ Health
System, but the clinical and operational performance
results are not the same. Assets such as Electronic
Health Record (EHR), Clinical Data Repository (CDR)
and Healthcare Data Dictionary (HCD) have common
roots between XYZ Health System and Intermountain
Health Care. However, Intermountain has been more
successful than XYZ in leveraging data assets for Clini-
cal Quality Improvement (CQI) and overall Health De-
livery System Performance Improvement. Hence, there
has been a new impetus at XYZ to learn from the suc-
cess of Intermountain and other leading health organi-
zations. This is the hallmark of a learning health orga-
nization such as XYZ. Understand what you are good
at, understand who is even better, and learn from them.
Approach
1. Analytics Evolution for CQI at Intermountain
Health Care
s What happened (in a clinical process) is about
a capability for learning
s Why it happened is about a capability for im-
proving
s What will happen and when will it happen is
about a capability for predicting
2. Use Deming and CQI principles for performance
improvement
s Conduct Pareto analysis to determine Clinical
Programs to focus on
— Identify the 20% of Clinical Programs ac-
counting for 80% of the costs. Identify the
1
Nudging implies moving something or someone gently
along in another direction.
2
In contrast to ‘‘nudging’’ ‘‘noodging’’ implies a borderline
pestering. However, this ‘‘pestering’’ within an organizational
context becomes acceptable once organizational leaders ac-
cept challenging goals that may entail extra assistance in or-
der for those goals to be reached
Consumer
Quality
People
Quality
Relationships
Technology Process
C itV l
I
CommunityValue
QualityQuality Mutual
Learning
II
Clinician
CommunityValue
Health System
CommunityValue
Figure 5: We now integrate the previous concepts into the full picture of the Learning Health
System. Knowledge intensive assets (People, Process, Technology and Relationships) are
converted by Innovation Engines into Quality, Community and Value by consumers
and clinicians individually and the Health System as a whole. All the while, the consumer and
clinician mutually learn from each other as well as enabling overall Health System learning .
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5. variability of these High Impact Clinical Pro-
grams
— Create ‘‘Clinical Program Conceptual Model’’
by creating matrix of High Impact Clinical
Programs vs. Clinical Support Services
s Define best practices within High Impact Clini-
cal Programs
s Measure performance and compliance
s Disseminate results
s Determine outcomes
3. To accomplish CQI, you need the data
s Intermountain did not take one of the two in-
dustry ‘‘best practice’’ approaches for Enter-
prise Data Warehouse (EDW)
— 1st approach (not taken): Make a compre-
hensive data model and then populate the
EDW
— 2nd approach (not taken): Create a series of
disease specific data marts or registries
— Hybrid Approach at Intermountain: Bring
over the labs, pharmacy and other ancillaries
first. Next, create focused data marts from
the ancillary data
s Need same persons who work on the informa-
tion model to also work on the terminology
s Have uniform concepts in the Healthcare Data
Dictionary then may have different terminolo-
gies to present these concepts to different user
groups depending on the group’s education
level
4. The secret sauce, however, is not in creating the
EDW. Rather it is how an organization leverages
the EDW
s Key differentiator of success for leveraging
EDW in Clinical Program improvement is the
organizational infrastructure set up to support
the improvement initiatives
s For each Clinical Program’s ‘‘Guidance Coun-
cil,’’ have a set of advisors including clinical
leader, data architect/modeler, data analyst, in-
formaticist, statistician, nurse informatician
s Each guidance council has a workgroup re-
sponsible for coming up with the data elements
needed for performance improvement in the
given Clinical Program
s The key is being parsimonious. If 50 clinical
terms gets you 90% of the way toward effective
condition management vs. 3000 terms that cov-
ers 99% of the condition management possibili-
ties, then go for the 50 terms approach
Conclusion
Intermountain Health Care succeeded in achieving
transformational results in Clinical Quality and Organi-
zational Performance Improvement because they lever-
aged a diverse skill set (People Capital) with new mod-
els for governance and new models for integrating the
skill sets (Process Capital) into specific Clinical Pro-
grams (condition focused service line). The People had
the right information assets and supporting analytical
applications (Technology Capital) and the People had
new lines of reporting that aligned improvement team
activities with incentives for improvement around Clini-
cal Programs (Relationship Capital). The physicians,
nurses, IT experts, and data analysts learned how to
work effectively with each other in a given Clinical Pro-
gram. Teams for the next Clinical Program tackled for
improvement learned from earlier improvement teams.
If replicated nationally Intermountain’s success would
take the U.S. Health System a long way towards the vi-
sion of becoming a Learning Health System.
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