Urgent Challenge: Put Evidence into Practice More Effectively

Healthcare outcomes in the United States are far from optimal. Patients' care experiences are often frustrating and fragmented—lacking clear care plans, plagued by slow or missing communication and unclear or unshared priorities, and fraught with challenges to access critically needed information and tools. Patients often are not fully engaged in reconciling their care goals with those of their clinicians to achieve important results. Furthermore, the United States has the poorest healthcare outcomes among 11 high-income countries, even though it spends the most (7). According to the Centers for Medicare and Medicaid Services (CMS), the United States spent 17.7% of its 2019 Gross Domestic Product (GDP) on healthcare—and costs are rising (8). A 2019 peer review of literature from 2012 to 2019 estimated approximately 30% of healthcare spending could be considered waste, resulting in a staggering total annual waste estimate of $760 billion to $935 billion and a potential $191 billion to $286 billion in savings from interventions that address waste, including in the following domains pertinent to this Roadmap (4):

• Failure of care delivery: $44.4 billion to $97.3 billion
• Failure of care coordination: $29.6 billion to $38.2 billion
• Overtreatment or low-value care: $12.8 billion to $28.6 billion

Despite the high expenditures, many are still uninsured or underinsured and substantial health disparities by race, ethnicity, and socioeconomic status exist (9). It can take over a decade for research-supported interventions to become standard care (10), and one New England Journal of Medicine study found that adults receive only half the care that is recommended (11). Preventable harm (e.g., medication errors) causes up to 1,000 deaths per day (12), and that does not include errors of omission. Approximately $210 billion/year is wasted on unnecessary services, while another $130 billion/year is spent on inefficient services and $55 billion is lost to missed prevention opportunities (13).
Clinicians are also burning out. Poor information flow also contributes to clinician burnout that costs billions every year (14) and further degrades care quality. A 2017 panel on physician burnout called it "a public health crisis" and described the pressure on doctors to meet quality measures without the resources or support to meet those demands (15). The 2019 novel coronavirus (COVID19) has exacerbated this problem (16). While high burnout is associated with lower quality care, the magnitude and clinical significance is still unclear (17) (18) (19). One contributor to burnout could be lack of resources needed to work more efficiently and effectively. Some estimate that physician decisions influence more than 80 percent of healthcare costs (20) (21), so efficiently supporting these decisions should be a priority. Valuable evidence-based resources, knowledge, and tools curated by AHRQ and others to guide decisions and actions to address these problems do exist, but they are underused. This may be due to potential users not being aware that these resources already exist, having poor access to them, or having difficulty integrating them within their workflow and underlying health IT systems.
Figure 2. High-Cost, Suboptimal U.S. Healthcare (12) (13) (14) (20) (11) (15)
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A common theme underlying these problems is suboptimal support for healthcare decisions and actions with helpful, evidence-based guidance and tools. Effective support requires a robust flow of essential information, tools, and resources around the LHS cycle, but as shown in Figure 3. Current Barriers to an Effective LHS Cycle this flow isn't happening well. This is due in part to myriad, fragmented, uncoordinated pathways whereby these assets are created and deployed (e.g., across patients, care teams, resource developers, insurance providers, hospitals, clinics, public health organizations, researchers, and many other users).

Figure 3. Current Barriers to an Effective LHS Cycle

In this broken supply chain, data, knowledge, information—and access to them—are siloed in disparate systems that are not interoperable. This problem is pervasive throughout the entire healthcare system, leading to inefficiencies, lost time and productivity, and undesirable outcomes. For example, healthcare organizations often experience difficulties to:

• Find, evaluate, access, and integrate into systems the data, evidence, guidance, and tools needed to support critical business decisions, products, and actions
• Apply pertinent data, guidance, and tools within time-pressured workflows
• Leverage complex and evolving standards to address business needs
• Manage increasing costs and challenges associated with public health, care quality, process efficiency, stakeholder satisfaction, and other key outcomes
• Interact effectively with the complex web of information "suppliers" and "customers" to deliver value

More specifically, there are significant missed opportunities at critical junctures along the LHS cycle. Data reflecting care results are frequently not used well to improve the evidence base because it is typically difficult and expensive to gather, incomplete, and/or inaccurate. This limited data scope yields evidence that does not address many important questions. Further, the evidence is often inconsistent and not in a standardized format, making it difficult to process into readily updatable knowledge, tools, and resources that support care delivery and transformation. The many support offerings that already exist are difficult to locate and apply. They often do not fit smoothly into workflow and can require major investments to acquire and deploy in health IT systems. The poor interoperability and flow from data to evidence to guidance to tools that support critical decisions and actions and back to data about care results is depicted in Figure 4. Current Healthcare Information Flow). This current state is a major driver for the preventable problems with care and patient outcomes, unnecessarily high expenditures, suboptimal patient experience, and overburdened clinicians noted above.

Figure 4. Current Healthcare Information Flow

These challenges led healthcare leaders to establish the Quintuple Aim(22) (23)—a goal where the healthcare system simultaneously enhances patient experience, improves population health, reduces costs, and improves clinician experience. Health information technology (IT) is widely considered a key enabler to improve information flow and achieve the Quintuple Aim. While there have been major investments in health IT (including artificial intelligence \[AI\] and cloud computing infrastructure), substantial standards efforts, and regulations around _data_ interoperability, there remains a chasm between the kind of transformation achieved in other industries and that seen in healthcare (2). There is growing consensus that health IT-enabled care transformation delivered through an LHS, both at the enterprise and national levels, supported by evidence and knowledge interoperability that complements data interoperability, is the solution to these deficiencies (24).

There have been major efforts over decades to address these problems, and this ACTS Roadmap builds on these efforts, a sampling of which includes: 

• Crossing the Quality Chasm, Institute of Medicine (IOM), 1996–2006 (1)
• Roadmap for National Action on Clinical Decision Support (CDS), The Office of the National Coordinator for Health Information Technology (ONC) / American Medical Informatics Association (AMIA), 2006 (25)
• Knowing What Works in Healthcare: A Roadmap for the Nation, 2008 (26)
• Driving Quality and Performance Measurement—A Foundation for CDS, 2010 (27)
• Optimizing Strategies for CDS, 2017 (28)

Full realization of LHSs and the Quintuple Aim in follow-up to these important initiatives have been impeded by forces such as:

• The lack of a specific, shared vision for how the cycle is supposed to function to help drive and coordinate enhancement efforts
• Inadequate funding and incentives to make these improvements
• The lack of widely adopted standards to improve resource development, interoperability, and implementation

This ACTS Roadmap deliverable builds on prior work and leverages more robust and widely adopted critical standards (e.g., Fast Healthcare Interoperability Resources \[FHIR\], more ubiquitous and sophisticated health IT (developed with greater attention to user-centered design), increased interest in value-based care and LHSs, and greater attention to stakeholder-driven approaches to accelerate transformation. These developments should substantially accelerate progress toward the Quintuple Aim beyond what these prior initiatives achieved. This Roadmap focuses on the problems and solutions that AHRQ and other knowledge ecosystem stakeholders can directly address by replacing the broken cycle, shown in Figure 3. Current Barriers to an Effective LHS Cycle and Figure 4. Current Healthcare Information Flow with an effective LHS cycle, shown in Figure 5. The LHS Cycle. In this effective LHS cycle, public health, care delivery, and quality improvement (QI) actions produce data about results, which is processed into evidence about effective actions, which is in turn processed into knowledge, tools, and resources that inform subsequent action—in a continuous cycle—to achieve the Quintuple Aim. Producing an effective LHS cycle requires that information flows seamlessly around that cycle. The environment in which people use processes and technology to address this flow in ways that deliver desired outcomes we call the "knowledge ecosystem."

Functionally, the knowledge ecosystem enables the LHS cycle, which we also refer to as the "knowledge ecosystem cycle."

Figure 5. The LHS Cycle

The CDS 5 Rights Framework (29), is a widely cited approach for putting evidence, guidance, and tools into practice better—that is, for optimizing the _guidance to action_ portion of the knowledge ecosystem cycle. The framework, recommended by CMS as a health IT / QI best practice (30), asserts that optimizing a particular healthcare process or outcome requires getting the information (e.g., evidence-based and actionable) to the right people (e.g., care teams and patients) in the right formats (e.g., registry reports, documentation tools, data display, care plans) through the right channels (e.g., electronic health record \[EHR\], personal health record \[PHR\], smartphones, smart home devices) at the right times (e.g., during a key decision or action). This framework can be extended to cover the _entire_ LHS cycle by broadening each of the five dimensions to include _all_ the pertinent who, what, when, where, how options.

Figure 6. The Decision/Action Support (DAS) 5-Rights-Supported LHS Cycle illustrates how the LHS virtuous cycle requires addressing well each of those five dimensions throughout all activities in the cycle.

Figure 7. LHS Functions That the Knowledge Ecosystem Supports illustrates additional details about processes performed around the knowledge ecosystem cycle. Each of these processes is an opportunity to put the DAS 5 Rights Framework into action to make them efficient and well-coordinated to achieve a virtuous LHS cycle.