The document discusses the concept of learning health care systems (LHCS) as a potential solution to the ongoing challenges in the U.S. health care system, including issues of quality, access, and cost. It highlights the Group Health Cooperative as a successful model of LHCS that integrates research and clinical practice, demonstrating improvements in patient care and cost efficiency. The document also outlines various initiatives and research efforts aimed at reducing waste and enhancing patient-centered care within the healthcare framework.

1. Learning Health Care Systems
Engines of Success for U.S. Health Reform?
Grand Rounds I Beth Israel Deaconess Medical Center I January 24, 2013
Eric B. Larson, MD, MPH
Vice President for Research, Group Health
Executive Director, Group Health Research Institute

2. Why this topic? Why today?
1999 2001
The IOM planted the idea of “learning health care systems”
more than a decade ago to solve the quality crisis.

3. More than a decade later…
We are still struggling to achieve “the triple aim”:
• Improving patient experience (quality & satisfaction)
• Improving the health of populations (better access)
• Reducing per capita cost

4. Berwick & Hackbarth on the problem:
Eliminate systemic waste (JAMA 2012)
Total U.S. health care system waste = $11 trillion over nine
years
“The savings potentially achievable from systemic,
comprehensive, and cooperative pursuit of even a fractional
reduction in waste are far higher than from more direct and
blunter cuts in care and coverage.”
4

5. A matter of professional ethics
To make a difference, we must address all categories at once:
• Overtreatment
• Failures to coordinate care
• Failures in care delivery
• Excess administrative costs
• Excessive health care prices
• Fraud and abuse
Addressing waste is a matter of professional ethics.
Waste must be addressed by professionals from within the
system.

6. Estimated annual waste by category
Single-year (2011) estimates based on a review of the waste
literature, after resolving overlapping areas:
6

7. What can be done?
Today’s system appears wedded to prevailing payment
arrangements.
Powerful forces have a strong stake in preserving the status quo.
(“It works for us.”)
Must we accept poor quality, lack of access, higher costs?
Some doubt the U.S. health care system can change itself:
• Stanford economist Victor Fuchs in The New York Times:
The only solution may be change that profoundly “unsettles
established interests.”
• He quotes Alexis de Tocqueville:
In the U.S., “events can move from the impossible to the inevitable
without ever stopping at the probable.”

8. Can learning health care systems
be the engines of change?
Overview of today’s talk:
• History and development of a learning health care system (LHCS):
Group Health Cooperative
• Potential opportunities for research in LHCS
• What we’ve learned about LHCS: Challenges & rewards
• How LHCS can help solve the crises in quality, access, cost

9. The challenges. The opportunity.
The IOM’s 2008 Roundtable on Evidence-Based Medicine
identified problems with U.S. health care:
• Evidence is often not available for clinical decision making.
• Uptake of new discoveries can be slow and false starts are common.
• Even when evidence is available, it is not applied consistently—meaning
variation, inefficiencies, and disparities persist.
Opportunity:
• We need a new clinical research paradigm.
• We need “learning health care systems.”

10. The challenges. The opportunity.
In learning health care systems, traditional principles of research
can be used in more practical ways so that:
• Decisions can be made more quickly.
• Better information is available for clinical decision making, for
managing health care delivery.

11. What is a learning health care system?
The IOM’s vision:
• Research happens closer to clinical practice than in traditional
university settings.
• Scientists, clinicians, and administrators work together.
• Studies occur in everyday practice settings.
• Electronic medical records are linked and mined for research.
• Recognition that clinical and health system data exist for the public
good.
Evidence informs practice and practice informs evidence.

12. One example: Group Health Cooperative
Founded in 1947 “To Serve the Greatest Number”

13. Today’s Group Health
A Seattle-based health plan serving 620,000 in Washington, Idaho
Combines health care and coverage
1,200 physicians and 9,500 staff
Nearly 2/3 of members get care at Group Health facilities
Annual revenue: about $3.3 billion
Includes Group Health Research Institute

14. Today at Group Health Research Institute
Non-proprietary, public interest
About 300 employees working on
more than 250 concurrent studies
39 scientific investigators, including
MDs, epidemiologists, biostatisticians,
health services researchers,
psychologists
33 affiliate investigators (mostly UW,
Group Health medical staff)
More than 300 publications in peer-
reviewed journals each year
Grant dollars in 2012: $46.3 million

15. Primary areas of research focus
Biostatistics Cancer Prevention
& Control
Women’s Health
Chronic
Improved health & Illness Care
Health Systems health care through
Organization & research, innovation
& dissemination Immunization
Finance
Preventive Care & Mental Health and
Health Promotion Behavioral Medicine

16. Research is in Group Health’s DNA
1947: Group Health’s original mission statement: “Contribute to
medical research”
1950s-60s: University-based researchers mine Group Health data
beginning in 1956 with the Seattle Longitudinal Study on Aging
1970s: Group Health’s own research on its preventive care services
began
1983: Group Health Research Institute (GHRI) founded with
Ed Wagner, MD, MPH, as director

17. Research is in Group Health’s DNA
1980s:
• NCI funds phone-based tobacco cessation research, leading to changes in
coverage, successful quit lines nationwide
• Bike helmet studies show link to reduced head injuries, leading to bike
helmet laws and wide-spread use
1990s:
• Chlamydia screening proven effective against PID; CDC recommends
Chlamydia screening
• Collaborative care proven effective for depression
Early 2000s:
• Alternative care can help back pain
• Improved diabetes care reduces cost

18. Highlights of GHRI’s first 25 years
Registries for breast cancer screening and immunization
• 1987: The nation’s first breast cancer screening registry and reminder
system
• 1988: 1 of 5 sites in the CDC’s first Vaccine Safety Datalink
• JAMA 1995: 32% reduction in late-stage breast cancer and 89% of 2-year-
olds have complete immunizations
• Both registries enable ongoing large-scale research that impacts clinical
recommendations and national standards
The Chronic Care Model
• Developed at GHRI’s MacColl Center for Health Care Innovation as a way
to improve diabetes care and outcomes
• Now used worldwide for diabetes, depression, congestive heart failure,
asthma, and other chronic conditions

19. Challenge: Linking research
to practice and vice versa
2002 “Access Initiative”
• Group Health has always been primary-care based; aspired to
be patient-centered.
• Reputation and past performance in “managed care” and as a
traditional HMO: Access was a problem.
Access Initiative elements included:
• Same-day appointments
• Open access to specialists
• A new EMR with secure website for members
• Ambitious productivity standards
• Reimbursement change

20. Challenge: Linking research
to practice and vice versa
University of Washington/Group Health study of “Access
Initiative” showed:
• Increased patient satisfaction
• Markedly improved access and productivity
• But no gains in clinical quality, and
• A dramatic negative impact on primary care provider work life
Next step:
• Patient-centered medical home pilot
• Can it improve quality and revitalize primary care?
• Our design benefitted from “lessons learned” through the
Access Initiative

21. Patient-centered medical home to
revitalize primary care
Genesis of medical home concept: Special-needs pediatrics
and internal medicine
Reinvigorated core attributes of primary care
More system support for chronic illness care
Advanced information technologies (EMR, registries,
reminders, patient portals)
Supportive physician payment methods (promotes medical
home goals, not simply volume)

22. Patient centered medical home to
revitalize primary care
Design principles for Group Health’s pilot:
• Panel size reduced from 2,300 to 1,800 patients
• Appointment times increased from 20 to 30 minutes
• Expanded multi-disciplinary clinical teams
• Desktop time for physicians
• E-technology and communication (EMR and secure e-mail
with patients)

23. 2-year evaluation shows positive results
Reid RJ et al, Health Affairs 2010;29(5):835-43
Larson EB et al, JAMA 2010; 306(16):1644-45
Reid RJ et al, Am J Manag Care 2009;15(9):e71-87

24. Patient experience in the medical home
Significantly higher scores for patients at pilot clinic Year Year
1 2
Quality of patient-doctor interactions
Shared decision making
Coordination of care
Access
Helpfulness of office staff
Patient activation/involvement
Goal setting/tailoring
Compared to Medical Home Medical Home Difference not
controls: higher lower significant

25. Staff experience in the medical home
Marked improvement in burnout levels at prototype clinic at 1 year
Medical Home Control Clinics
Emotional Exhaustion
Baseline 44.4% 54.2%
12 month 19.4%
** 54.5%
Depersonalization
Baseline 25.0% 25.0%
12 month 18.8% 30.4%
Lack of Personal Accomplishment
Baseline 25.0% 18.2%
12 month 10.0% 25.6%
-60% -40% -20% 0% 20% 40% 60%
** p<0.01
% Patient Care Employees rating as "Moderate/High"

26. Utilization & costs in medical home
Year 1:
• 29% fewer ER visits
• 11% fewer preventable hospitalizations
• 6% fewer but longer in-person visits
• No significant difference in total costs between medical home
and control clinics
Year 2:
• Significant utilization changes persisted
• Overall patient care costs lower at medical home (~$10 PMPM)

27. Lessons learned from Group Health’s
patient-centered medical home pilot
Patient-centered care saves costs by lowering inappropriate use
of emergency care and avoiding preventable hospitalizations.
Investment can achieve relatively rapid returns across a range of
key outcomes, even in an already integrated system.
The evaluation provides some of the first empirical evidence of
the benefits of the medical home.
The evaluation gave leadership the confidence to invest $40M in
redesign of primary care, spreading the medical home to all 26 of
its medical centers.
The evaluation served as a model for our evolving learning
health care system.

28. Group Health’s concept of
a learning health care system (LHCS)

29. Unwarranted variations in surgical care
are pervasive in the U.S.
The Dartmouth Atlas Project has found widespread geographical
variation nationwide in the use of elective surgical procedures.
Patients in Wenatchee, WA are three times more likely to have
their arthritic knees replaced than are similar patients in Honolulu.
Men in Bellevue, WA are much less likely than those in Thousand
Oaks, CA to undergo surgery for benign prostate disease.
This variation reflects physician training and preference—not what
patients want or need.

30. Variation within the Group Health system

31. More LHCS projects have followed
Example: Shared decision making
2007: Washington State passes nation’s first law endorsing
shared decision making (SDM)
SDM provides shelter from liability
State mandates demonstration projects, leading SDM research at
Group Health.

32. More LHCS projects have followed
Example: Shared decision making
In 2009, Group Health launched a system-wide shared decision
making initiative
12 video-based decision aids in six specialty services:
• Orthopedic: hip and knee osteoarthritis
• Cardiac: coronary heart disease
• Urology: benign prostatic hyperplasia and prostate cancer
• Women’s health: uterine fibroids and abnormal uterine bleeding
• Breast cancer programs: early-stage breast cancer, breast
reconstruction, and ductal carcinoma in situ
• Back care programs: low back pain from spinal stenosis and herniated
disc

33. SDM is not new to Group Health,
but translating findings is
Group Health published studies on the value of SDM for BPH and low
back pain the mid-1990s. Results: High patient satisfaction, lower cost.
But we lacked mechanisms to move such findings into practice.
Wagner EH et al,
Med Care
1995;33(8):765-70

34. Health Affairs: September 2012

35. SDM conclusions to date
Large scale implementation of patient decision aids is feasible
Use of decision aids for SDM appears to be one way to achieve the
“triple aim” in health care
Improves patient satisfaction (& knowledge)
Appears to lower rates of elective surgery
Reduces costs or is at least cost-neutral
Is generally well-accepted by providers
Offers potential for greater liability protection

36. Preliminary findings in women’s
health and urology
Treated Untreated Prostate AUB/
BPH BPH Cancer Fibroids
Impact on
Impact on
surgery use
surgery use
Impact on
Impact on
health care
health care
costs
costs
Unpublished findings

37. LHCS example: Reducing harms
from advanced medical imaging
Group Health study shows wide variation in radiation exposure from
computed tomography (CT) scans and increased use over time.
Smith-Bindman R et al,
JAMA
2012;307(22):2400-9

38. LHCS example: Reducing harms
from advanced medical imaging
Estimated that CT-induced cancers could be reduced by 40% if the
highest 25% of radiation doses from pediatric CT could be lowered to
the median dose.
Based on these results, Group Health began developing ways to
lower radiation exposure from medical imaging.
Researchers and the radiology service collaborated to provide CT
technologists with feedback reports, training on CT doses.
The technologists are eager for more education and want to engage
radiologists in discussions about developing dose monitoring
protocols.
Researchers will evaluate whether dose-feedback reports and dose-
reduction education reduce radiation exposure for Group Health
patients.

39. LHCS example: Addressing risks of
chronic opioid therapy
An epidemic of prescription opioid abuse
Group Health Research Institute:
Higher opioid dose linked to
prescription opioid
16000 overdose risk in chronic pain
cocaine patients (Annals of Internal
14000
heroin Medicine, 2010)
12000
Number of deaths
Washington State guideline:
10000 Safe opioid prescribing requires
8000 clinical evaluation, treatment
agreements, periodic monitoring,
6000 urine drug screening, and
medical records treatment
4000 documentation
2000
Federal Action Plan:
0 Epidemic—Responding to
'99 '00 '01 '02 '03 '04 '05 '06 America’s Prescription Drug
Abuse Crisis (Office of National
Year
Drug Control Policy, April 2011)

40. LHCS example: Addressing risks of
chronic opioid therapy
Group Health launches a comprehensive opioid prescribing
safety initiative in 2010.
• Objectives: standardized practices, clarification of treatment goals and
expectations, fewer cases of abuse, misuse, and overdose
• Standardized care plans: one responsible prescribing physician, refill
planning and monitoring, urine drug screening for high-risk patients,
referral guidelines
• Training: Web-based CME on how to implement the standardized care
plans, funded by the Group Health Foundation
The initiative produced stunning results that outpaced the federal
call to action (April 2011)….

41. LHCS example: Addressing risks of
chronic opioid therapy

42. LHCS example: Addressing risks of
chronic opioid therapy
Cumulative
By May 2011, 85% of Group Health chronic opioid
therapy patients had documented care plans.
7,000
6,000
5,000
No. care plansper month
4,000
3,000
2,000
Note: Chronic opioid therapy defined as having
filled at least 5 prescriptions in the past 90 days or
1,000
taking opioids for at least 90 days in a pattern or
quantity that indicates daily or near-daily use.
0
06/01/10 07/01/10 08/01/10 09/01/10 10/01/10 11/01/10 12/01/10 01/01/11 02/01/11 03/01/11 04/01/11 05/01/11
Month Cumulative
Today, COT care plans at Group Health are nearly universal.

43. Partnership for Innovation:
An opportunity to pilot clinical staff’s ideas
Group Health Group Health
care-delivery system Research Institute
• 1,200 physicians • Non-proprietary, public
• Patient-centered care interest science
• Aligned incentives to innovate • Focus on practical research
for better care
Group Health
Partnership for
Innovation
• Ideas come from Group Health staff
• Funded by Group Health
Foundation
• Group Health Research Institute
helps design & evaluate

44. Partnership for Innovation
Grantee selection criteria
• Will it promote better care at a lower cost?
• Is it a new process, product, or service?
• Is it an incremental change?
• Is it patient centered?
• Is it feasible?
• Does leadership support the work?
Some examples…

45. Pediatric intranasal flu vaccine
Total funding: $75,532
Innovation
Provide painless flu-vaccine option
for children
Potential benefits
• Increase flu vaccination rates
• Increased patient/family satisfaction
Results
• Parents perceived intranasal vaccine as risky
• Uptake was lower than expected
• Intranasal vaccine program dropped

46. Outpatient orthopedic ultrasound
Total funding: $34,897
Innovation
Diagnosing shoulder injuries in
outpatient setting with portable
ultrasound device
Potential Benefits
• Less use of high-end imaging
• Higher patient satisfaction
Results
• Demonstrated reduction in MRI usage
• 200 percent return on investment
• Will expand system-wide

47. Learning health care systems can address
the BIG questions for U.S. health care
What’s the best use of limited resources?
What works? What doesn't?
How can we cut out waste, inefficiencies, errors?
How can we leverage the strengths of integrated care systems?
How can we address the problems of an aging population?
How can we address growing burdens of chronic illness?
How can we contain costs so we can afford to care for the
expanded number of people who will soon have coverage?

48. What we have learned in developing a
LHCS at Group Health
We can learn more quickly, produce more timely results.
Research can align with the care-delivery system’s business goals.
We always strive for projects that are:
• Generalizable
• Public-domain
• Leading to nationally relevant discoveries and solutions
Funding these projects can be challenging, but not impossible.

49. What does the future hold for LHCS?
New sources of support:
Patient Centered Outcomes Research Institute
• Founded in 2010 under the Affordable Care Act
• Nonprofit, nonfederal, independent
• Patient and stakeholder input influences all phases
• Patients and stakeholders are reviewers
• Budget: $3 billion for 2012-2019

50. What does the future hold for LHCS?
New sources of support:
Health Care Systems Collaboratory
• Established by NIH Director Francis Collins, MD, PhD, through the
Common Fund
• Engaging health systems in large clinical studies
• Coordinating Center at Duke University funded in 2012
• $11.3M for first year
• Includes HMO Research Network (19 integrated health plans)
• Recently funded seven “pragmatic trials” to develop and spread
best practices—includes studies of suicide prevention, colorectal
cancer screening, and care for low back pain

51. What does the future hold for LHCS?
New opportunities through large, multi-site studies:
Example: The Mini-Sentinel
• Funded by the FDA
• Active, extensive surveillance system to monitor the safety of
regulated medical products
• Gathers data from 29 health care organizations nationwide

52. Conclusion
The potential is rich.
Can Victor Fuchs’ assessment be right? Will change only come
through an unraveling of the current system?
Or can we make our learning health care systems the engines of
success for U.S. health reform?
Let’s take this as a matter of professional ethics, exercising
professional obligations to our patients.
Let’s drive the change, achieving de Tocqueville’s prediction of
inevitable and positive change.

53. Questions?