Learning Health Systems: A Paradigm Shift in What We Can Do about Digital Health Inequities.

Learning health systems (LHSs) embed social accountability into everyday workflows and can inform how governments build bridges across the digital health divide. They shape partnerships using rapid cycles of data-driven learning to respond to patients' calls to action for equity from digital health. Adopting the LHS approach involves re-distributing power, which is likely to be met with resistance. We use the LHS example of British Columbia's 811 services to highlight how infrastructure was created to provide care and answer questions about access to digital health, outcomes from it and the financial impact passed on to patients. In the concluding section, we offer an accountability framework that facilitates partnerships in making digital health more equitable.

Building the foundation for a practice-based research network: supporting primary care research across Canada.

Context: The Strategy for Patient Oriented Research (SPOR) was designed to engage previously passive stakeholders in the research process to ensure that the most urgent health challenges are addressed with evidence-based solutions that are feasible and scalable. The Primary and Integrated Health Care Innovations Network (PIHCIN), one of multiple SPOR entities, is rooted in community-based primary health care and meant to support transformation of primary and integrated care to improve patient experiences and health. Objective: To describe key components of building the foundation for a cross-jurisdictional, practice-based research network. Design: Cross-sectional survey and PIHCI network documentation review. Setting: SPOR PIHCI networks within British Columbia; Alberta; Saskatchewan; Manitoba; Ontario; Quebec; New Brunswick; Nova Scotia; Prince Edward Island; Newfoundland and Labrador; and the Northwest Territories. Participants: Responses were received from 11 networks who completed a template asking about their governance, capacity building, stakeholder engagement and patient partners. Responses were also received from the SPOR PIHCIN Pan-Canadian Patient Council. Outcome Measures: Thematic analysis across responses and documents for key components foundational to PIHCIN: types of stakeholders engaged, types of capacity building activities, knowledge translation and exchange activities. Results: Tripartite (clinician, scientist, decision-maker) leadership was used to align more closely with provincial and territorial needs in bringing practice and research closer together. PIHCIN enabled a unique pan-Canadian forum for government staff responsible for primary care. Individual networks and the PIHCIN patient-partners were actively engaged in research and governance on all levels including leading their own research. PIHCIN built research capacity by partnering with the Transdisciplinary Understanding and Training on Research Primary Health Care (TUTOR-PHC) and embedding fellows within the network. The PIHCI network undertook two separate learning series featuring patients, policy makers and scientists that were open to the public and demonstrated clear impact. Conclusion: Foundational components of embedded patients-partners, tripartite leadership, capacity building and knowledge translation and exchange have led to the formation of the PIHCI network providing an excellent base to build a pan-Canadian practice-based research and learning platform.

Implementation and Outcomes of Virtual Care Across a Tertiary Cancer Center During COVID-19.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few quantitative data support its rapid implementation and positive associations with service capacity and quality. Objective: To examine the outcomes of a cancer center-wide virtual care program in response to the COVID-19 pandemic. Design, Setting, and Participants: This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020. Main Outcomes and Measures: Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients. Results: The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946. Conclusions and Relevance: These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.

Innovative Policy Supports For Integrated Health And Social Care Programs In High-Income Countries.

As high-income countries face the challenge of providing better and more efficient integrated health and social care to high-needs and high-cost populations, they may require innovative policy supports at both the national and local levels. We categorized policy supports into four areas: governance and partnerships; workforce and staffing; financing and payment; and data sharing and use. Our structured survey of thirty integrated health and social care programs in high-income countries in 2018 found that the majority of programs had policy supports in two or more areas, with supports for governance and partnerships and for workforce and staffing being the most common. Financing and payment and data sharing and use were less common. Local partnerships empowered integration across sectors, and new staff roles that spanned health and social care embedded this integration in care delivery. National policies-including bundled financing and investment in data-enabled integration and cross-sector accountability.

Innovative Integrated Health And Social Care Programs In Eleven High-Income Countries.

High-income countries face the challenge of providing effective and efficient care to the relatively small proportion of their populations with high health and social care needs. Recent reports suggest that integrated health and social care programs target specific high-needs population segments, coordinate health and social care services to meet their clients' needs, and engage clients and their caregivers. We identified thirty health and social care programs in eleven high-income countries that delivered care in new ways. We used a structured survey to characterize the strategies and activities used by these programs to identify and recruit clients, coordinate care, and engage clients and caregivers. We found that there were some common features in the implementation of these innovations across the eleven countries and some variation related to local context or the clients served by these programs. Researchers could use this structured approach to better characterize the core components of innovative integrated care programs. Policy makers could use this approach to provide a common language for international policy exchange, and this structured characterization of successful programs could play an important role in spreading them and scaling them up.

Using Human-Centered Design to Build a Digital Health Advisor for Patients With Complex Needs: Persona and Prototype Development.

BACKGROUND: Twenty years ago, a "Guardian Angel" or comprehensive digital health advisor was proposed to empower patients to better manage their own health. This is now technically feasible, but most digital applications have narrow functions and target the relatively healthy, with few designed for those with the greatest needs. OBJECTIVE: The goal of the research was to identify unmet needs and key features of a general digital health advisor for frail elderly and people with multiple chronic conditions and their caregivers. METHODS: In-depth interviews were used to develop personas and use cases, and iterative feedback from participants informed the creation of a low-fidelity prototype of a digital health advisor. Results were shared with developers, investors, regulators, and health system leaders for suggestions on how this could be developed and disseminated. RESULTS: Patients highlighted the following goals: "live my life," "love my life," "manage my health," and "feel understood." Patients and caregivers reported interest in four functions to address these goals: tracking and insights, advice and information, providing a holistic picture of the patient, and coordination and communication. Experts and system stakeholders felt the prototype was technically feasible, and that while health care delivery organizations could help disseminate such a tool, it should be done in partnership with consumer-focused organizations. CONCLUSIONS: This study describes the key features of a comprehensive digital health advisor, but to spur its development, we need to clarify the business case and address the policy, organizational, and cultural barriers to creating tools that put patients and their goals at the center of the health system.

Building Bridges to Integrate Care (BRIDGES): Incubating Health Service Innovation across the Continuum of Care for Patients with Multiple Chronic Conditions.

Integrating care for people with complex needs is challenging. Indeed, evidence of solutions is mixed, and therefore, well-designed, shared evaluation approaches are needed to create cumulative learning. The Toronto-based Building Bridges to Integrate Care (BRIDGES) collaborative provided resources to refine and test nine new models linking primary, hospital and community care. It used mixed methods, a cross-project meta-evaluation and shared outcome measures. Given the range of skills required to develop effective interventions, a novel incubator was used to test and spread opportunities for system integration that included operational expertise and support for evaluation and process improvement.

Capturing the experiences of patients across multiple complex interventions: a meta-qualitative approach.

OBJECTIVES: The perspectives, needs and preferences of individuals with complex health and social needs can be overlooked in the design of healthcare interventions. This study was designed to provide new insights on patient perspectives drawing from the qualitative evaluation of 5 complex healthcare interventions. SETTING: Patients and their caregivers were recruited from 5 interventions based in primary, hospital and community care in Ontario, Canada. PARTICIPANTS: We included 62 interviews from 44 patients and 18 non-clinical caregivers. INTERVENTION: Our team analysed the transcripts from 5 distinct projects. This approach to qualitative meta-evaluation identifies common issues described by a diverse group of patients, therefore providing potential insights into systems issues. OUTCOME MEASURES: This study is a secondary analysis of qualitative data; therefore, no outcome measures were identified. RESULTS: We identified 5 broad themes that capture the patients' experience and highlight issues that might not be adequately addressed in complex interventions. In our study, we found that: (1) the emergency department is the unavoidable point of care; (2) patients and caregivers are part of complex and variable family systems; (3) non-medical issues mediate patients' experiences of health and healthcare delivery; (4) the unanticipated consequences of complex healthcare interventions are often the most valuable; and (5) patient experiences are shaped by the healthcare discourses on medically complex patients. CONCLUSIONS: Our findings suggest that key assumptions about patients that inform intervention design need to be made explicit in order to build capacity to better understand and support patients with multiple chronic diseases. Across many health systems internationally, multiple models are being implemented simultaneously that may have shared features and target similar patients, and a qualitative meta-evaluation approach, thus offers an opportunity for cumulative learning at a system level in addition to informing intervention design and modification.