Overview

The Future Vision Workgroup considered four distinct perspectives for the future vision for an LHS: care delivery, organizational LHS/care transformation, resource developer, and national LHS. As stated in the Consensus Future Vision for Evidence-Informed, Health IT Enabled Care Delivery & Transformation section, Figure 15. Future Vision for a Virtuous LHS Cycle illustrates the future vision for a seamless, continuously improved flow around the LHS cycle. This cycle represents a learning health cycle whereby knowledge and resources that support care delivery and care transformation support action by those engaged in this work. This action generates data about results which are synthesized into evidence for guiding decisions and actions that is processed into knowledge and resources. Knowledge and resources are then applied to healthcare and their effects are studied to generate additional data to repeat the cycle.
The Care Delivery Future Vision Perspective (B.3) defines how patients, non-professional caregivers, and health professionals apply knowledge, tools, and resources to improve decisions, actions, and communications. The future vision includes a better experience of care processes for both patients and health professionals than is the case today. The Resource Developers' Future Vision Perspective (B.4) defines a future vision for people engaged in developing guidelines and health IT tools, such as EHRs and CDS interventions, in which they have better access to the evidence needed to create and maintain their offerings. The Organizational LHS Future Vision Perspective (B.5, B.5.1) similarly outlines a state where QI teams and others have better access to data and tools to make their work more efficient and effective, and less stressful. The National LHS Future Vision Perspective (B.5, B.5.2) illustrates how the entire LHS cycle can operate better as a virtuous cycle without obstacles and fragmentation.

Introduction to the Future Vision Workgroup Effort

The Future Vision Workgroup was established by the ACTS Stakeholder Community (52) to define the future vision from the four perspectives listed above. The Future Vision Workgroup consisted of 29 members from a wide range of CDOs, informatics researchers, clinical IT developers, CDS content developers, and policy organizations. Subgroups within the Future Vision Workgroup addressed each of the four perspectives (both LHS perspectives were developed by a single subgroup) and vetted the care delivery future vision with patients, care teams, and CDO leaders.
The Future Vision Workgroup met weekly by web conference to review the developing documents, provide feedback, and exchange ideas among the groups. The purpose of the Future Vision Workgroup was to create a consensus future vision for the four perspectives to serve as the destination to be reached by executing the stakeholder-driven ACTS Roadmap. Each perspective subgroup added specificity to the broader healthcare goal of achieving the Quintuple Aim. The Future Vision Workgroup sought to define a future state of healthcare that is so compelling that anyone with a stake in the future vision perspectives would be motivated to work toward achieving that future vision as part of Roadmap execution efforts.
The guiding principles of the future vision are to:

1. Use health IT to bring evidence-informed tools and resources to the point of need so they can be adopted with little or no additional effort by the user
2. Make care delivery more patient-centric by using health IT tools and methods to enhance information sharing, communication, and patient participation in care plan development and implementation
3. Use health IT effectively to improve care and care transformation processes while lessening the burden and improving satisfaction and outcomes for those involved

The audience for the Future Vision Workgroup reports reflects the constituencies that developed them: patients and care team members, CDOs, clinical IT developers, CDS content developers, guideline developers, policy makers, and research funding agencies. Key audiences within these groups include both high-level decision makers, who guide strategy and operations, as well as those who do the daily work the future vision aims to improve.
The deliverable of the Future Vision Workgroup consists of this summary, dedicated sections for each of the four perspectives (organizational and national LHS perspectives are combined in a single appendix), and a summary of the care delivery future vision vetting and results.

Care Delivery Perspective of the ACTS Future Vision

Care is proactive, evidence-based, personalized, patient-directed, and anchored by the patient-centered medical home (PCMH) (196). Sophisticated health IT tools enable these capabilities in a manner that is seamless and user-friendly for patients, care teams, and those who support them. Patients have access to tools that enable them to communicate easily and exchange information with providers and drive the development, implementation, monitoring, and updating of care plans aimed at achieving the patient's health goals.
Workflow enhancing, knowledge-based tools enable diverse healthcare professionals working in different settings to function efficiently as an integrated care team to optimize care and outcomes for individual patients and populations. For example, systems enable pertinent care team members to gather key information proactively from the patient and other sources before their visit to make encounters more productive and provide updates on new data and plans produced during the encounter to the entire team. Nonurgent updates are "on-demand" while more urgent developments are conveyed proactively.
Decision support tools, integrated with care planning and monitoring tools ensure that care is evidence-based, important information and interventions are not overlooked, and all members of the care team are informed about and understand their role in the care plan. Shared decision-making tools used in developing care plans ensure that the plan is optimized to achieve patient goals. Population management tools, mobile apps, EHRs, patient portals, and other health IT tools support care plan execution and ensure that patients get all the right care to support their goals—and no contraindicated care.
Health IT-enabled best practice workflows—adapted as needed to local and patient-specific circumstances—make "the right thing to do easy" and help ensure that potential gaps in care are proactively prevented. When this fails, the gaps are detected and addressed promptly. Telehealth tools enable care to be provided and monitored outside of care delivery settings and, when appropriate, with engagement by the patient's caregivers and family members.

How Patients & Care Teams Experience This Future State

During a patient's normal daily routines, they have convenient access to resources and tools, informed by the best evidence, to improve their health and their satisfaction with their care by:

• Helping them address questions that arise about their health via portals that respond to the need and context (See Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal and Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results)
• Supporting shared decision making and information sharing with all those on their lay and professional care teams and easy communication with members of the care team (197)
• Automatically showing patients the care they need in a personalized and understandable way, via links to educational materials and decision aids in a patient portal
• Actively participating in the development of care plans that integrate and health management approaches across all of their providers and care settings
• Supporting team-based care for proactive management, with key information readily available to all members of the team
• Providing guidance and tools for managing health issues including pathways for step-by-step guidance to achieve health goals, links to social support systems and apps that pull data from the care plan and medical record and local support resources (e.g., regarding nutrition, exercise, community programs) to assist in making personalized health decisions and acting on them successfully
• Making the process of care more patient focused
• Sharing tools that enable them to find clinicians based on transparent pricing and quality of care metrics that matter to them

During a professional care team's normal daily routines, they have convenient access to resources and tools, informed by the best evidence, that improve their work satisfaction and care processes and results for individual patients by:

• Helping them gather, integrate, prioritize, and review critical patient data to enable proactive healthcare
• Making the right decisions, actions, and documentation the easy thing to do—including supporting shared decision making with patients—in ways that fit smoothly into clinical workflow (198)
• Providing requested clinical information and guidance via portals that deliver vetted, evidence-informed information that is responsive to the particular need and context (see Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal and Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results)
• Streamlining and optimizing communications and collaboration with patients and others on their care team, as well as with community-based resources
• Optimizing care for individual patients and entire populations through a population management perspective that helps identify and close care gaps across all patients

Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal and Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results show a portal mockup that illustrates how patients and clinicians can access needed answers, guidance, and resources (not addressed by care plan templates) from AHRQ and others in a manner more sensitive to the users' perspective then is typically available today. Notice the filters for patient, clinician, care resource developer, and QI team beneath search box and the search results organized into different categories. These figures are for illustration/discussion purposes only and are not a proposal or recommendation.

Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal

Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results

A key resource supporting proactive, patient-centered, evidence-informed care in this future vision is a tool for supporting care development (see Figure B-3. Care Plan Support Tool Mockup Interface) that:

• Supports collaborative care plan development and implementation by patients and all the care teams and caregivers that support them
• Coordinates user input and activities across patient/caregiver, care teams, specialities, facilities, and organizations
• Is accessible at any time by anyone with authorized access
• Is interoperable across different systems and organizations (including those outside the organization where the patient's care plan was originally developed)
• Is based on evidence-based care plan templates for preventive care and for managing common and important acute and chronic clinical issues (gathered automatically based on patient's active clinical problems)
• Includes support for addressing the common situation where patients have multiple chronic conditions
• Uses convenient, workflow-friendly shared decision-making tools that help patients and care teams adapt problem-specific care plan templates (individually and when aggregated to cover the patient's conditions) to patient-specific goals, circumstances, and preferences based on data from the EHR, the care team, and the patient
• Reconciles the combined set of problem-focused care plans into a unified/integrated care plan that provides a coherent and feasible evidence-informed set of actions and, ultimately, has development and implementation that will be enhanced by AI and machine learning (ML) approaches and tools (199) (200) (201) (202) (203) (204)
• Provides workflow-friendly order sets, documentation templates, protocols, and other tools so that any care team members (including the patient) can initiate and track care as directed by the plan
• Supports a care model that both increases preventive services and provides problem-based support both within and outside of traditional office encounters
• Evolves the patient's care plan as circumstances change based on input from the patient and the care team, data from information systems, and updated evidence and recommendations (which are automatically delivered to care plan templates and patient-specific care plans)

Figure B-3. Care Plan Support Tool Mockup Interface illustrates some of these features. It is a mockup to foster discussion and not a proposal or live system.

In this mockup, after all relevant data are input into the Care Plan Support Tool, the "Review CarePlan" function at the top right of the graphic generates a unified plan across the patient's conditions.
The future vision for care delivery is further described in B.3, Care Delivery Perspective of the ACTS Future Vision.

The Care Journey

This section of the Future Vision Appendix outlines a highly desirable future vision for the health/care delivery journey. It makes concrete a core element of the destination targeted by the ACTS Roadmap deliverable—that is, improved information flow, workflow, and outcomes for those who give and receive healthcare. The future vision perspective illustrates steps where evidence-informed tools support patients and their care teams in making decisions and taking actions that will produce outcomes aligned with the Quintuple Aim.
The patient journey brings to life key interventions believed to provide the foundation for next-generation health IT and evidence-enabled care (see B.3.8, Assets Currently Available Related to the Future Vision). The goal for this patient journey is to evoke from diverse stakeholders (especially patients and caregivers) reactions such as:
"If care were broadly delivered as illustrated in this future state, my constituency, organization, and I would be closer to achieving our goals and healthcare would move closer to the Quintuple Aim. This future vision is so compelling that we will work toward its realization."

Current State of Care Delivery

Current care-related workflows, staffing, training, reimbursement, financial incentives, content development, and technologies do not support such a future state well. The ACTS Roadmap focuses on steps AHRQ and others can take to deliver information resources needed for this future vision. However, these other barriers and their implications will also be made explicit. See B.3.5, Principles Underlying the Care Delivery Future Vision and B.3.7, Gaps/Offerings Related to Interventions & Scenario.
Clinical Perspective: Gaps to be addressed in achieving the future vision include:

• Reduction in the number of portals patients must negotiate
• Easy navigation to community support resources
• Symptom evaluation tools and pre-visit questionnaires with automatic triggering of the appropriate tool based on presenting complaint or problem
• Integration into clinical care of patient-generated data including automated devices
• Care guidelines, appropriate to the patient and delivered at the point of care without interruption of workflow
• SMART and flexible documentation templates
• Shared decision-making tools, triggered automatically for appropriate decisions
• Dashboards for the patient and members of the care team to determine the patient's status and unaddressed needs
• Dynamic links to knowledge sources integrated with the EHR
• A care plan generator that is accessible to and allows input from all members of the care team, the patient, and non-professional caregivers

The current state of primary care doesn't support the idealized model due to both internal (practice) and external (regulatory, payment) factors. Payment and technology enablers will need to support eliminating many time-consuming activities that don't add value (198) and creating and nurturing the alternative high-value activities outlined in the desired future state. Patients and the lay and professional care teams will need ongoing support and coaching in order to move toward the idealized model. Workforce development and redeployment of existing personnel will be needed to fully achieve this vision. Additional personnel costs may be a perceived barrier in some settings but are likely to be offset by increases in efficiency.
A springboard for this care delivery future vision work was an AHRQ video (205) that outlines how care for a patient with multiple chronic conditions ("Mae") would be much more efficient, effective, and patient-centered if it were driven by an evidence-based care plan. This care plan, developed with Mae and all those involved in her care, would coordinate and support the development and implementation of actions to optimize Mae's health and wellbeing.
The ACTS Initiative's work to articulate a care delivery future vision began with adding additional conditions to Mae's problem list to leverage important pertinent work by AHRQ and others and laying out an idealized health journey for Mae that leverages next-generation approaches to using evidence informed tools and resources to support decisions and actions. The desire was to include detailed who, what, when, where, how information for this journey so that implementers in care delivery and resource developer organizations could provide input into realizing these desired details.

Current State Patient Journey

Mae is a 63-year-old female for whom you have provided primary care for 10 years. She is widowed and lives in town by herself; although her adult daughter visits her frequently to see how she is doing. You have treated her for hypertension and osteoarthritis. Recently, you had to stop the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for her osteoarthritis pain due to progression of stage 3 CKD. Acetaminophen has been ineffective, as has a recent trial of tramadol. You elected to start her on low doses of opiates (oxycodone, 5 mg every 4 hours). This was initially effective in that it reduced her pain, improved her function, and enhanced her overall quality of life. However, Mae told you after several months that it wasn't working as well as it had at the start of treatment and requests a stronger dose via a phone message. You ask the patient to come in for a visit to review her pain control program.

Resulting Office Visit—Current State

You gather additional pertinent information. She shares that she sometimes takes more oxycodone than prescribed because of her pain. Your review of the prescription drug monitoring program (PDMP) confirms that she has run out of medication and requested renewals early the last two times. She also states that she is feeling depressed and attributes that to loneliness after the loss of her husband and having to deal with significant pain every day. She denies any thoughts of suicide but tends to stay at home most of the time due to the depression and chronic pain, even though her daughter tries to get her out to the mall or to a restaurant. You share with Mae that she may be developing a mild OUD and shows signs of depression—quite understandable given her loneliness and chronic pain. You suggest she start a new medication—duloxetine—which may help both her chronic pain and her depression and ask that she return for a visit to check on how she is doing in 3–4 weeks. You ask if her daughter can accompany her at that visit, only to learn that the daughter works full time and can't come during your office hours.

Follow Up Visit—Current State

Mae reports reduced pain and somewhat better mood. Her blood pressure now catches your attention, and you realize that she may need an additional antihypertensive and that she is overdue for a check of her renal function. For the next several months, over a series of several office visits, you closely monitor her pain and overall function, her blood pressure, and her renal function. Although all those issues eventually seem to be responding to treatment, you realize that she is overdue for pneumococcal immunization, a mammogram, and some form of colorectal cancer screening. You recommend a colonoscopy because, if normal, it will buy you and Mae a full 10 years before you need to remember to repeat the procedure. You refer her to a gastroenterology group and tell her that "all the doctors in that group are great." You also order a mammogram and ask her to schedule a visit soon to get her cervical cancer screening updated.

Problems With the Current State

Note that although this clinical team seems to have provided reasonable care, the care is reactive rather than planned. There is a delay in the identification and treatment of problems. The recommendation for colon cancer screening is not patient-centered because the patient's preferences are not elicited for shared decision making. Care is done exclusively in the office, requiring several office visits for Mae and more time for history taking by the clinical team. All care is dependent on the doctor and not the broader care team. There is no effort to gather important information prior to office visits, which takes time away from the physician's interaction with the patient. Care is not coordinated with Mae's family nor is there any apparent attention to Mae's social isolation. There is no mechanism to identify gaps in care (such as the overdue mammography) proactively, so closing them depends on an office visit which may not occur in a timely manner. Although Mae's care might be considered appropriate given the current lack of effective technology and financial resources for most primary care offices, we can do much better.
This state of affairs is not entirely due to lack of awareness on the part of the clinical team. Clinicians know that evidence-based tools exist to personalize care and share decision making, but they are not practical to find and apply real-time in practice. Health IT supports for care planning and execution are not adequately available and those that are available are underused. Functionality needs to be re created in each system, which is costly and impractical. Lack of these tools results in a limited ability to personalize care to the person or setting and there is suboptimal patient engagement in defining and carrying out care. The concept of developing formal care plans is not universally (or even widely) known or practiced.

Future Vision for Care Delivery

In proposing a future state of care delivery, we consider seven phases of a patient's Where "patient" is mentioned throughout this scenario, consider it to broadly include patient and any caregivers supporting them. journey through the healthcare system. These are:

1. At home when symptoms develop
2. Pre-appointment planning for an office visit
3. Primary care visit and initiation of integrated care plan
4. Post-encounter care and implementation of care plan
5. Additional encounters with providers and modifying the care plan
6. Selecting a primary or referral clinician
7. Population management

The ideal future state assumes the existence of a PCMH that provides comprehensive, patient-centered care coordinated with an emphasis on quality, safety, and easily accessible services. It also assumes the availability of a multidisciplinary care team that includes, in addition to a health provider (e.g., physician, advanced-practice nurse, or physician assistant), care coordinators and navigators who can:

• Gather data from the patient and other care providers
• Assist with arranging appointments with other providers and for diagnostic testing
• Locate and connect the patient with social services and community resources
• Provide monitoring outside of the office setting to enable early intervention and close gaps in care through a population health approach

This future vision is articulated with the realization that it involves a wealth of resources that may not be rapidly achievable in many practice settings, but it provides a goal toward which long-range planning should aspire.

Interventions Interventions that are patient-facing (e.g., activation/self-management tools, questionnaires, shared decision-making tools), are tailored to optimize patient comprehension and engagement (e.g., have appropriate, reading level, language, cultural sensitivity). Underlying Care Delivery Future Vision

Table B-1. Interventions Underlying the Future Vision lists the health IT-enabled interventions that provide the building blocks for the highly desirable future vision for care delivery—and otherwise supporting patients' health journeys—with evidence-informed tools and resources. This table is informed by from a similar table in the patient-centered CDS OAP (page 16) (56) upon which the future vision scenarios are based. Note: there's significant interplay, and in some cases overlap, among these interventions.

Table B-1. Interventions Underlying the Future Vision

Future State Patient Journey: Details Through Seven Stages/Settings

Mae has contacted your office via the patient portal about her need for stronger pain medication. Care team members respond and ask her to provide some additional information prior to her visit (i.e., tools that screen for possible OUD and depression and assess her level of pain and function). Results of the screening tools reveal mild OUD, mild-to-moderate depression with no suicidality, and that Mae is having more trouble with housekeeping and meal preparation and has very few activities outside the home. All of this is communicated to the professional care team via the portal before her visit.
By the time Mae arrives for her office visit, you and the care team are well into creating an integrated care plan since you have the benefit of important relevant information gathered in advance, shared via the portal, and integrated into Mae's EHR. This information helps populate a dashboard with the latest function/pain information and opioid use history, including a PDMP report. You tell Mae that the screening tools she completed confirm a significant loss of function and overall quality of life, as well as mild OUD and mild-to-moderate depression. You suggest the addition of duloxetine, and because so much time has been saved by data gathering and reporting in advance, you are able to spend more time discussing the diagnoses and treatment recommendations and jointly creating a care plan that Mae understands and agrees with.
The EHR makes it easy for you to arrange for a follow up contact in 2–3 weeks via a telehealth visit, with both Mae and her daughter via a secure video link. Once again, data gathered and organized by protocol before the visit sets up a productive virtual encounter. During the virtual visit, Mae's affect and functional state are improved as indicated on the pre-visit data forms, and her daughter (seated at a computer terminal in her private office at work) provides additional examples of this improvement and asks what more could be done to help with her arthritis. The integrated care plan automatically suggests having Mae see a physical therapist and an occupational therapist to help with her arthritis. Because the therapists are linked with your EHR via a health information exchange (HIE), they have a more complete picture of her circumstances than they typically had before they were linked. With Mae's permission and her daughter's knowledge, you make a proactive referral to the local area Agency on Aging to develop options to reduce Mae's social isolation. You send Mae's information to the agency, and they contact her to offer options for meeting other community members in the context of entertainment or games, but also suggest Mae reconnect with her faith community, rediscover her love of gardening, consider a pet dog, or start mindfulness-based therapy.
While not the focus of the original call from Mae or the initial visit, the care plan supports attention to condition management and preventive services through workflow-friendly order sets, protocols, and other tools for any care team member to initiate and track care. The patient portal automatically shows patients the care they need and integrates into your population health tools so some of these items can be addressed by care coordinators outside of office visits. As a result, Mae is up to date with her breast cancer screening and all recommended immunizations prior to this care episode. She and her daughter know that she is due to update her colon cancer screening. She has used a shared decision-making tool and decided she wants a FIT test and not a colonoscopy. This can be arranged with a single-click order. She also has a home blood pressure monitor that links to your practice portal and you see that despite somewhat elevated readings at office visits, her home readings are on target and there is no need for additional antihypertensive medications.
The FIT test is positive, so despite her preference, Mae now needs a colonoscopy. She finds the provider comparison tool on the HHS website. Using the list of gastroenterologists you recommended, Mae enters her zip code, specifies a distance she is willing to travel, and the gastroenterologists who are accepting new patients within those parameters are listed. She can rank them based on cost and key quality parameters, including colonoscopy time to completion and perforation rate. She selects the gastroenterologist who best matches her quality priorities and clicks on the "Request Referral" button in her portal that informs you of her choice.

Patient's Symptoms Deteriorate at Home (Before an Integrated Care Plan is in Place)

Ideally, the patient should have an established connection with their medical home (196) through a patient portal. The patient consults the portal or an app at home for information to better understand what is happening and to get guidance on helpful next steps (Table B-1, Intervention 1) Numbers in parentheses refer to interventions outlined in B.3.8 Assets Currently Available Related to the Future Vision.. This connection should provide:

• Explanations for possible symptoms and causes of deterioration (Table B-1, Intervention 4)
• Immediate steps to manage deterioration, including listing "alarm conditions" that warrant urgent attention such as engaging the lay and/or professional care team or seeking emergency care (Table B-1, Intervention 2) (e.g., by activating an immediate phone or telehealth consultation (Table B-1, Intervention 9))
• Guidance on when and how to contact the care team (Table B-1, Intervention 2)
• Other self-care activities to better manage symptoms before the clinical encounter, and additional information about underlying clinical conditions to better understand their natural history and best overall management strategies (Table B-1, Intervention 2)
• Tools to document symptoms and condition severity including influencing factors to guide self-care and to share with clinicians to support diagnosis/management plan (Table B-1, Intervention 5)
• Pre-visit questionnaire to elicit the patient's goals, priorities, and concerns for the next visit (Table B-1, Intervention 7)
• Transmission to the primary care team of data from the self-assessment tools before the visit (Table B-1, Interventions 1, 2, 4, 5, 7)
• Patient (or proxy) books appointment as recommended by the self-management tools (Table B-1, Intervention 2) using the patient portal or app

Care Team Prepares for Productive Patient Visit (Pre-Appointment Planning by Team)

Pre-visit Planning at Medical Home. Before the patient comes in for the visit, the primary care team reviews patient-generated data (Table B-1, Interventions 1, 2 ,4, 5, 7) and gathers tools, questions, and interventions that will likely be needed during the visit. Additional activities that might occur prior to the visit include:

• Sending the patient additional data collection forms. Questions (e.g., extensions of Table B-1, Interventions 4, 5, 6, 7) are sent by the care team via text or portal (Table B-1, Intervention 1) to gather additional data needed to inform shared decision making and care planning related to the patient's problems and their goals for the visit; patient responses are automatically imported into the appropriate place in their EHR.
• Querying a HIE for key data from other sources to help with care (Table B-1, Intervention 16). Currently, most HIEs require manual search and retrieval of information. In the future, this is likely to be automated as a "push" process to the EHR. However, reconciliation of the incoming information will likely always require manual confirmation.
• Populating the care plan. Because the patient doesn't have an integrated care plan, the care team activates an EHR function that creates a care plan template (Table B-1, Intervention 14), and then directs the EHR to populate that template with each patient problem and with relevant pre-visit data obtained from the patient. The template includes links to evidence-based tools that support problem management (e.g., Table B-1, Interventions 2–8, 14–15, 19)
• Huddling to review data. On the morning of the patient visit, the professional care team huddles to review data (Table B-1, Interventions 2, 4, 5, 6, 7) and the care plan template (Table B-1, Intervention 14) and determine what additional data gathering, shared decision making, and further care planning and execution is needed. Since this patient has multiple providers, there are mechanisms connected to the care plan tool (Table B-1, Intervention 14) for the primary care team (including the patient) to communicate with other care team members that aren't in the same place to inform them and give them an opportunity to collaborate on care planning.

Patient Has Primary Care Visit (to Develop and Implement Integrated Care Plan)

Care Plan Developed with Medical Home. Prior data gathering and tool setup sets the stage for a highly productive visit to better manage the patient's immediate concerns and provide more integrated, evidence-based, patient-centered care going forward. An integrated care plan (Table B-1, Intervention 14) developed and initially executed during this visit is the key resource for making this happen. During the visit, the team will:

• Review prior data. During medical assistant (MA) intake, prior data are reviewed and validated (including the patient's agenda for the visit) and new data are gathered (Table B-1, Interventions 2, 4, 5, 6, 7) per protocol from the care plan template (Table B-1, Intervention 14). This may include, for example, a problem-specific questionnaire or instrument to assess symptoms or severity of a condition.
• Support history/physical exam documentation and additional data gathering. The provider and the patient use the patient's data (Table B-1, Interventions 2, 4, 5, 6, 7) and template-generated documentation tools (Table B-1, Intervention 10) activated by the care plan, to support additional data gathering and documentation to inform decision making and care planning and execution.
• Use shared decision-making tools. The patient and provider use shared decision-making tools (Table B-1, Intervention 11) to determine specific actions for further diagnostic, therapeutic, and monitoring activities for each problem (including preventive care). For this patient, an example would include a discussion of different options for colorectal cancer screening.
• Establish and initiate care plan (see Figure B-3. Care Plan Support Tool Mockup Interface). The care plan is the best approach based on organizational care protocols (Table B-1, Intervention 13), which are in turn informed by evidence-based guidelines (8) but tempered by the patient's insurance specifics, preferences, priorities, and SDOH and other considerations. The care plan defines goals and success criteria, timelines, roles, and responsibilities and anticipates risks and barriers to successful implementation of the care plan and strategies to mitigate these barriers (Table B-1, Intervention 14).
  • Initial care plan execution by the provider is supported by evidence-informed order sets (Table B-1, Intervention 17) generated in response to care plan details. Order sets cover tests, treatments, and referrals in ways that address the patient's preferences.
  • The care plan includes education and self-management information and tools for the patient (Table B-1, Intervention 2), which the care team reviews with the patient before the end of the visit.
  • The care plan lists everyone on patient's current care team in order to share the care plan (including underlying evidence and other drivers) to all team members to help optimize and coordinate care (Table B-1, Intervention 14). This care team member list is available via the EHR, patient portal, regional HIE, and other health IT channels as appropriate.
  • Governance procedures are in place to ensure that all members of the care team are contributing as expected.

After Office Encounter (Patient/Care Team Implement the Care Plan)

Care Plan Implemented

The integrated care plan addresses the patient's clinical problems and concerns as well as preventive care, and guides the patient and their lay and professional care teams in coordinated actions that optimize the patient's health and satisfaction, as well as other Quintuple Aim outcomes. The care plan is accessible on the portal, smartphone app, and/or paper. It has been agreed to by all those affected and is used and contributed to by all those authorized by the patient on their lay and professional care team. Defining who may contribute to overall care plan management will be determined by organizational policy and patient input. The patient follows the steps specified in the care plan (Table B-1, Intervention 14). The patient uses self-management support tools (Table B-1, Intervention 2), documentation tools (e.g., to capture/track information about pain and function, self-measured blood pressure readings) (Table B-1, Intervention 5), wearable devices and others that are further customized based on their individualized care plan (Table B-1, Intervention 14) as the foundation for self-management efforts.

• Uses information about pertinent/helpful community-based resources (Table B-1, Intervention 3) to help make agreed-upon lifestyle changes and otherwise address social determinants and other factors influencing health.
• Communicates with the care team with questions or concerns not addressed by care plan through the patient portal or app (Table B-1, Intervention 1), telehealth application (Table B-1, Intervention 9), encrypted phone or other route.

Additional Encounters (Monitoring & Modifying the Care Plan & Synchronizing Efforts Across Providers)

Care Plan Used & Modified Across Providers/Settings

As the patient's health journey unfolds, they encounter different providers (e.g., medical home team, specialists, physical therapists) and different settings (e.g., office, urgent care, or ED visits, hospitalizations, long-term care). In each case, the integrated care plan is the foundation for decision making and action based on patient preferences and pertinent data/history, clinical evidence, and proactive planning by all care team members.

• During subsequent encounters, the care plan is used and modified as appropriate based on circumstances and patient preferences, as well as guideline-informed (Table B-1, Intervention 8) care protocols (Table B-1, Intervention 13). Technology and governance are in place to support care plan access, use, and evolution, including details such as who may modify the care plan. Patient monitoring/management dashboards (Table B-1, Intervention 12) provide an overview of condition-specific actions and results to help track progress and identify helpful changes to the care plan when needed.
• Shared decision making tools (Table B-1, Intervention 11), clinical calculators (Table B-1, Intervention 15), and any other of the applicable tools are leveraged as appropriate to support effective, evidence-informed, patient-centered decisions, actions, data gathering, and documentation.
• All those authorized, receive updates to the care plan and related events as appropriate, and communications are facilitated as needed to ensure that the care plan remains an integrated tool. To accomplish this, it must be capable of exchanging data with various EHRs covering the patient and the patient's portal(s) and/or APIs (Table B-1, Intervention 14).

Clinician Selection

Transparency is sorely needed in healthcare so that patients have information about the cost of care and the quality of service they might receive from a clinician, clinic, hospital, or health system. As we work toward the Quintuple Aim, reducing costs and improving quality, the definition of improving value requires much greater participation by patients in the selection of where and how to receive clinical care. There is a compelling argument to be made that if we do not enable patients to make cost comparisons based on the quality of services that matter to them, we will never get to true value-based healthcare. "Value" should not be defined solely by health plans and health systems; it must reflect patients' views of value. As a result, the issues that matter most to them will not drive the system toward the value defined by others unless the two definitions of value coincidentally align. In transparent healthcare:

• Patients define the quality metrics that matter to them. Likely to be at the top of the list: chance of survival, quality of life, risk of complication, durability of resource or intervention, and quality of the patient experience. For a patient considering a colonoscopy, this might be mortality rate, risk of perforation or post-procedure hospitalization, and time to next colonoscopy or identification of colon cancer with subsequent care by this specific clinician or team. They are also likely to consider whether a provider treats them respectfully, provides necessary information, is accessible for communication, and makes it easy to arrange the procedure.
• Patients access tools that benefit from standardized definitions of services so that a colonoscopy at health system A covers all of the same care as a colonoscopy at health system B. There must be standard definitions of numerators and denominators for mortality, complications, and time interval to either return for service or diagnosis of cancer (as a missed diagnosis). These tools can then accept the quality metrics that matter to the patient to rank available clinical service options.
• Patients generate accurate estimates of their out-of-pocket costs (within 5%) by inputting a few pieces of demographic data, the procedure code, and their insurance policy number into cost generators that provide price transparency for "shoppable" healthcare services and procedures. (207)

Population Management Perspective (Care Gaps for the Patient & Population are Identified & Closed)

Ensure Entire Population Receives Best Care Related to population health, the care delivery future vision includes mechanisms to connect patients to pertinent research studies related to their condition (e.g., through patient-facing apps/portals have options (with easy to understand consent forms) for patients to donate their data to research studies).

The patient steps outlined in the previous sections focus on an individual patient. Population health complements those activities with a CDO's focus on the entire population.

• Care managers use reports from patient/condition registries and data warehouses (Table B-1, Intervention 18) to identify important gaps in care across the population based on guidelines (Table B-1, Intervention 8) and protocols (Table B-1, Intervention 13). This includes using care gap detection and notification tools (Table B-1, Intervention 19) that identify these gaps and notify appropriate parties proactively for selected conditions.

• These care managers work to close these gaps through outreach to affected patients in coordination with their care team. This includes reinforcing or modifying these patients' care plans (Table B-1, Intervention 14), leveraging other pertinent interventions (see Table B-1) as appropriate, and documenting new information, recommendations, and actions in the EHR (e.g., patient monitoring/management dashboard \[Table B-1, Intervention 12\] and care plan \[Table B-1, Intervention 14\]).

• Taking action to close gaps may require the use of shared decision-making tools as described above in Mae's choice of colorectal cancer screening modality.
• Transformation coaches work with clinical areas that have more than an expected number of gaps in order to prevent future gaps by educating the care teams and improving related care processes.

Principles Underlying the Care Delivery Future Vision

1. Quintuple Aim achievement is essential for both practical and ethical reasons.
2. We should promote patient autonomy.
3. We should promote shared decision-making, recognizing that this process involves a series of stages with varying content. (208)
4. We should support both lay and professional care teams.
5. The feasibility and sustainability of the initiative will be greater if we address work in primary care that should be abandoned, that should be added, and that should be continued. We must also address work that can be offloaded from providers to other clinical staff to free providers to spend more face time with patients and more time using critical thinking skills rather than administrative work.
6. Infrastructural approaches are needed for doing and supporting all of this.

Assumptions Underlying the Care Delivery Future Vision

1. The current state of primary care does not support the idealized model due to both internal (practice) and external (regulatory, payment) factors.
2. To fully achieve the desired future state, payment and technology enablers will need to support eliminating time-consuming activities that do not add value and adopt and nurture the alternative high-value activities outlined in the desired future state.
3. Patients and the lay and professional care teams will need ongoing support and coaching in order to move toward the idealized model.
4. We must assess the patient's and the lay and professional care team's ability and willingness to use the idealized care framework and tools to co-create the desired future state.
5. Keys to success will involve attention to technology, tools, and means for creating and sustaining collaborative lay and professional care teams.

Gaps/Offerings Related to Interventions & Scenario

The following tables describe the gaps and next steps to address the necessary improvements to the interventions defined in Table B-1. Interventions Underlying the Future Vision and necessitated by the Mae scenario. They also list some existing resources from AHRQ and others that could be leveraged or enhanced to realize the future vision for those interventions.
Table B-2.Gaps to Address / Next Steps

Assets Currently Available Related to the Future Vision

Table B-3.Current AHRQ Assets That Support Future Vision Interventions

Table B-4.Assets From Others Besides AHRQ That Support Future Vision InterventionsA recent Frost and Sullivan report (348) on the growth and growing importance in the CDS market asserts predicts growing importance and use of CDS interventions of this sort; this Care Delivery Future Vision the broader ACTS Roadmap can help ensure this evolution delivers optimal benefits.

Table B-5.AHRQ Assets for Addressing the Specific Needs of "Mae Scenario"

Table B-6. Non-AHRQ Assets for Addressing Specific Needs of Mae Scenario

Care Delivery Future Vision Vetting

Staff from three organizations, VCU, the NACHC, and Health Hats (Acknowledgements), shared the care delivery future vision for feedback with various clinical and lay stakeholders outside the Stakeholder Community to validate its core concepts and identify issues in achieving this vision:

• VCU shared the care delivery future vision with eight family medicine practices in Virginia and one health system's ambulatory QI committee, and investigators met with interviewees in person for 30–60 minutes
• NACHC shared it with a 15-member QI Advisory Board, and conducted a single 45-minute focus group by telephone
• Heath Hats shared it on a variety of social media platforms, yielding nearly 1,000 reads that generated 30 substantive comments from individuals

Respondents were sent a high-level summary of key care delivery future vision elements, a narrative of current primary care for a fictitious patient, "Mae," a second narrative of how Mae would receive and participate in her care in a future vision context, and discussion questions soliciting feedback on the future vision, what elements are already feasible, what new elements should receive priority, and obstacles to overcome.

Summary of Vetting Results

Processes used in this outreach and resulting findings are summarized in aggregate, then followed by more details for each.

Desirability of Overall Future Vision & Workflows, Tools & Resources That Support Them

In general, clinicians and patients felt the future vision was desirable, with caveats. Both groups felt attention to social needs, like social isolation, was critical. Clinicians wanted reasonable expectations and appropriate support for new care paradigms. Patients felt that there needed to be more explicit attention to patient and caregiver assumptions, concerns, and goals.

Challenges: Issues, Concerns, Requirements & Gaps to Address for Successful Implementation of Future Vision Workflows/Tools

The high-tech aspects of the future vision are not uniformly available (e.g., reliable internet access). Not all patients would be able or want to use them even if they were available, so workflow, paper, and relationship remain important tools. Decision aids must support true shared decision making, including attention to cost. Care plans must be functional, living documents. Any new tools and technology should make it easier for clinicians to deliver care as they are already suffering from information overload and unwieldy EHR function. The future vision also depends upon an adequate primary care workforce that is receiving support to deliver idealized models of primary care in partnership with patients and communities.

Current State: What Parts of This Can Be Accomplished Today Using Tools Available Now?

Respondents indicated parts of the care delivery future vision that could be accomplished today include communication via portal, team care models, systematic attention to prevention and chronic disease management that is evidence-based, and continued attention to longitudinal relationships between clinicians and patients as well as team-based care.

Path to the Future State: What Will It Take to Achieve the Future Vision?

Respondents indicated the most important thing necessary to achieve the future vision is a commitment to address all the challenges listed. Some of this will require policy changes, payment, and new technology systems that must be supported or demanded by the electorate.

Prioritization: What Parts of the Future Vision Are Priorities for Implementation Within the Next Year? In 3–5 Years?

• Next Year: Interoperability, HIE, and easy-to-use tools in EHRs that support EBM
• 3–5 Years: Better resources to address social needs, universal internet access, and an expanded and well-supported primary care workforce

VCU Individual Vetting Processes & Results

Who? What Entities/Roles Will be Exposed to ACTS Future Vision for Feedback?

Those exposed to the ACTS Future Vision included primary care clinicians from across Virginia, both health-system-owned and independently owned. Altogether, eight practices were visited from northern and southeastern Virginia, along with a focus group of the ambulatory QI committee for a large system in southwest Virginia.

How? To What Scenario Elements Will They Be Exposed & How Will This Be Conveyed?

Staff shared the Mae current scenario, the Mae future vision scenario, and the questions that made up our interview guide in advance of a site visit. Staff recorded all interviews, had them transcribed, and provided the transcripts to qualitative researchers in our department (Family Medicine and Population Health) who did the primary analysis. Tony Kuzel and Alex Krist did secondary analyses and edited the final report.

When & Where? When/Where Will This Exposure Happen?

All site visits and interviews were conducted in late July and most of August 2019.

What? What Data/Feedback Will Be Sought From Respondents & How Will It Be Documented?

Respondents listed tools and strategies currently in use for similar patients, feedback on the future vision, essential steps to achieve it (short- and long-term), and knowledge/use of AHRQ tools to enhance primary care.

VCU Feedback Summary

Desirability of Overall Future Vision & Workflows, Tools & Resources That Support Them

All respondents felt the future vision was desirable and would result in better care for Mae and a better care experience for her, her lay support team, and professional care team. Some thought that a subset of patients would only want in-person interactions and would struggle with IT-based interventions.

Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools

Respondents cited several challenges: lack of adequate attention to non-medical needs that affect health; lack of universal internet access; lack of IT interoperability; inadequate primary care workforce; inadequate support for primary care function; current technology often not easy to use and doesn't support needs; lack of payment models to support future vision care.

Current State: What Parts of This Can Be Accomplished Today Using Tools Available Now?

Respondents indicated the following could be accomplished with tools available today: communication via portal, team care models, systematic attention to preventive services, and chronic disease management that is evidence-based.

Path to the Future State: What Will It Take to Achieve the Future Vision?

Respondents indicated the future vision could only be achieved with a commitment to address all the challenges listed above, some of which will require public support (electorate) for needed policy changes.

Prioritization: What Parts of the Future Vision Are Priorities for Implementation Within the Next Year? In 3–5 Years?

• Now: Interoperability/HIE function; building in easily used tools to support EBM in EHRs
• Later: Universal internet access, adequate primary care workforce, adequate resources to support ideal models of primary care

What Are We Missing? What Other Issues Are Important That We Haven't Addressed?

Respondents indicated the care delivery future vision should also address the linkage between the self-directed IT-based interventions with direct support from the personal clinician and care team.

NACHC Individual Vetting Processes & Results

Who? What Entities/Roles Will Be Exposed to ACTS Future Vision for Feedback?

NACHC extended the opportunity for feedback to its 15-member QI Advisory Board, representing a geographically diverse, national cross-section of health centers, primary care associations, and health-center-controlled networks.

How? To What Scenario Elements Will They Will Be Exposed & How Will This Be Conveyed?

NACHC sent its advisory board a version of the future vision, including the Mae current state and future vision scenarios adapted from VCU's write-up.

When & Where? When/Where Will This Exposure Happen?

NACHC hosted a virtual feedback session August 26, 2019. QI Advisory Board members received a future vision concept document in advance of the call, which included discussion questions.

What? What Data/Feedback Will Be Sought From Respondents and How Will It Be Documented?

QI Advisory Board members were asked to provide feedback on the areas outlined by the workgroup (desirability, challenges, what's missing, etc.). Jerry Osheroff facilitated the discussion. NACHC opened the call, managed logistics, took notes, recorded the discussion, and shared notes back with the ACTS Project team.

NACHC Feedback Summary

Desirability of Overall Future Vision & Workflows, Tools & Resources That Support Them

Participating members of NACHC's QI Advisory board expressed overall interest in the proposed future vision state, with one individual noting, "It is a wonderful case study, and the person-centered approach is very much aligned with the care delivery model we are working hard to create." Another stated: "As a primary care provider, I always very much enjoy seeing what the future can look like and what could potentially be supported. It's very exciting to see where you're going with this."

Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools

A majority of members expressed caution, pointing to issues of accessibility, patient-centeredness, resource constraints, and community integration. There was consensus that the vision was "highly digitized," with a potential overreliance on technology that might be supplemented by greater consideration of workforce, policies, and community resources.

Accessibility

Nearly all participating QI Advisory Board members highlighted potential accessibility barriers for patients in the future vision. Comments pointed to the importance of considering health literacy, language, and patient access to and comfort level with technology. Key ideas included:

• Language Interpretation:
  • "I'm in a practice where probably 75% of the time my visits are interpreted, and so when we talk about these tools, I think they're great, but are they really going to be accessible to everyone?"

  • "Many of us had concerns about the accessibility of some of the standardized tools like CAHPS surveys for patient experience. AHRQ had developed a toolkit that my understanding was to help with organizations that had the resources to be able to make the tool accessible for other languages...\[but\] it almost felt like \[payors\] had a choice whether or not they actually did that."

• Health Literacy:
  • "I've read through the future scenario. It sounds so highly digital... We deal with a lot of populations that have whether it's cultural or language or other limitations or literacy. ...even for people who can read and access all the information, how we move people along or get them to that understanding... it's a big leap of faith for me."

Resources

Multiple advisory board members raised the question of reimbursement, recognizing that discussion of a future vision of care cannot be wholly separated from resource considerations—both in terms of money and time. They encouraged ACTS to acknowledge that implementing comprehensive interventions requires time and to consider how proposed services could be reimbursed.

• "We try to do much of the same thing but are limited with some of the technological aspects because those services are not able to be reimbursed. The reimbursement model also makes it difficult to invest the time necessary for such comprehensive interventions."
• "...the issue of resources is outside of the scope of this discussion...but I think that really is a big driver in how priorities get set sometimes, unfortunately."

Partnership/SDOH

Participants stressed that an ideal future vision state must integrate community-based resources and facilitate partnerships between care teams and community services to better address patients' comprehensive needs, including SDOH. One individual specifically identified "home visits by community health workers" as a missing element of the proposed vision:  "Health centers are working to address social determinants of health of patients and working a lot with community partners outside the four walls of the health center. How the care team can have those very productive relationships with community partners will be an important part \[of the Roadmap\] as well."

Patient Centeredness

Advisory board members commented on the importance of framing the future vision around the patient and her needs and preferences. One individual identified his highest priority interventions as: 1) shared decision-making tools, and 2) patient education and self-management tools. Another participant observed that the current and future states described in the sample patient scenario both put the onus on the patient to take action; instead, she suggested that the future vision present a more proactive role for providers.

• "What's missing \[from the proposed future vision\]: understanding of Mae's motivations for improving her health, other options in case Mae isn't comfortable with telehealth and how she would best like to receive care."

• "In both \[scenarios\] it seems to be that it's up to the patient to be the one that reaches out. While in the second scenario there are other options in which to do this. The observation I make is that we currently...have tools that could make it possible for us to be more proactive and not wait for the patient to initiate the request."

Other

Advisory board members also stressed that a roadmap for transformation must accommodate different care settings and have the ability to be applied flexibly depending on workflows and needs: "... a lot of these tools were developed in more of a research type of setting and so translating them into primary care with a safety net population... there's going to be some nuances for how that needs to happen...Just having those tools laid out so that they can be implemented in such a way that works best for the care team... and some examples or model practices that an organization could consider depending on their workflows because it's going to look different depending on their workflow."
Another participant commented that the proposed "Integrated Care Plan" lacked standardization: "seems like there's no standard, nor standard definitions, nor standard terminology, nor standard way of sharing that."

Current State: What Parts of This Can Be Accomplished Today Using Tools Available Now?

Participants also observed that, in many senses, they were already familiar with the components that are described in the proposed future vision state. One individual suggested that instead of identifying what care elements we should be moving toward the question would be better framed as, "why aren't we there yet?"
"When I look at the list that's in the table that has 19 items on them, all of those actually seem pretty familiar to us in the health center world. I don't mean to speak for everyone, but I think that we all look at these and we know what they mean. What that says to me is, to some degree, the future is already here, it's now, and so what's the reason why we're not really realizing the full benefits of all these things?"

Path to the Future State: What Will It Take to Achieve the Future Vision?

See B.3.9.3.5.2, Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools.

Prioritization What Parts of the Future Vision Are Priorities for Implementation Within the Next Year? In 3–5-Years?

No input

What Are We Missing? What Other Issues Are Important That We Haven't Addressed?

One advisory board member also raised the importance of better leveraging AHRQ's evidence-based resources to inform public policies that impact patients: _"There's a lot that we know that's evidence-based that could actually better inform public policy... things like policies that could better promote physical activity or access to healthy foods...\[that\] have more to do with what the community structure and infrastructure is like."_ Please also see B.3.9.3.5.2, Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools.

Health Hats Individual Vetting Processes & Results

Who? What Entities/Roles Will Be Exposed to ACTS Future Vision for Feedback?

Respondents were exposed to the ACTS Future Vision via LinkedIn (1,700 connections, 414 views, patient/caregiver activists, clinicians, academics, developers), Twitter (710 followers, 430 reads), Facebook (HealtheVoices (23 reads), Society for Participatory Medicine (15 reads), PPICOnline (91 reads), Engagement Buddies (21 reads), WEGO Health), and 30 other substantive comments were received via mediums used, emails, and phone calls.

How? To What Scenario Elements Will They Be Exposed & How Will This be Conveyed?

Health Hats posted the Mae current state and future vision scenarios and discussion questions.

When & Where? When/Where Will This Exposure Happen?

Respondents could access the future vision materials July 30–August 9, 2019 on social media (LinkedIn, Twitter, and Facebook).

What? What Data/Feedback Will Be Sought From Respondents & How Will It Be Documented?

Health Hats complied replies collected via direct message, text, and email.

Health Hats Feedback

Desirability of Overall Future Vision & Workflows, Tools & Resources That Support Them

In general, this future vision was considered desirable.

Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools

• Education must include understanding patient and family caregivers' concerns and assumptions (e.g., that any findings on an MRI or other imaging mean docs know the cause of pain)
  • Also missing how to address the emotional aspect that causes people to make decisions too quickly or presume more invasive options must be more effective
• Decision aids on their own are not effective. Clinicians must also be trained in SDM, or decision aids can create problems and can disintermediate the patient/clinician relationship
  • Most decision aids are unable to address cost/coverage issues, and clinicians are often unable to give clarity into this as well
  • Clinicians also need to be familiar with what's in the decision aid, which usually includes options outside their specialty and rarely includes integrative med options
• Online decision aids exist, and can be prescribed, but too many of them assume health literacy with an existing condition
• When a care plan/treatment journal is completed or updated who does this?
  • Is there a common repository for all the information, similar to Google docs where multiple people have access to read and edit/add?
  • This information is a living document; how would this work?
  • There would be a lot of consents completed to include many family members and community partners to access the document potentially
  • I think this is a great idea and will require people to really think of functionality without the current constraints, rather what it could be and try to remove constraints if they are too restrictive

Current State: What Parts of This Can Be Accomplished Today Using Tools Available Now?

No input

Path to the Future State: What Will It Take to Achieve the Future Vision?

• I wonder if clinicians should be asking (who are your three or five who would drop everything and be there for you no matter what)
  • If answer is "not sure or don't know"—how might clinicians help solve?
  • I think social isolation is a serious and growing epidemic
  • I wonder if clinicians were to ask some version of, "Who are you going to tell about your visit and what are you going to say?" would that check for loneliness and check for the most important thing discussed?
• Have you discussed using NQF's patient passport, or AHRQ's question builder to help frame conversations between clinicians and patients?
  • I am a bit concerned with reliance on electronic means of communication especially for elderly and potentially disadvantaged patients who may not have access to or understand the technology
  • Is there a paper alternative if need be or will patients be provided training in accessing electronic means?
  • Need to include community pharmacies as a piece/entry point for this as many patients go there first for advice on meds
• Maybe an enhanced medication report, one that's color coded and written in everyday LR language like hypertension med= image of heart and called "Heart meds" and opiates have a notation about addiction risks and short-term use?
• PatientWisdom.com makes it easy for patients to share what matters to them.

Prioritization: What Parts of the Future Vision Are Priorities for Implementation Within the Next Year? In 3–5 Years?

No input

What Are We Missing? What Other Issues Are Important That We Haven't Addressed?

• What if patients/families were directly invited to help tackle some of the main issues affecting a clinic/hospital (e.g., we are struggling with staffing, what ideas might a patient from another industry bring)?
• What if all clinicians sought out "patient/family" mentors and sought them out the way they do with medical faculty mentors?
• Info about cost and coverage, which is variable and very tricky
• I would like to see something in here about Mae's values and goals
  • Perhaps she prefers to try non-pharmaceutical options first, or perhaps she is working toward a specific health goal that she would like all of her care providers to support
  • We tend to frame care plans as being about what we (the health system) want for the person, not what the person wants or him/herself
• Also, there should be a goal about reconciling and clarifying any conflicts in the instructions she receives from various doctors
• If Mae wants, she should also be able to contribute a version of her medical history
• Incorporate contextual education so Mae can get educated as she looks at her data from lab results to conditions to medication

Resource Developers' Perspective of the ACTS Future Vision

The future vision workflows and information flows for care delivery and transformation (both at the organizational and national levels) are powered by health IT-enabled tools and resources. These include evidence-based guidance and answers to clinical questions, related tools for developing and executing patient-centered care plans, and many other offerings that support the virtuous LHS cycle. Many different organization types produce these resources aimed at making the right healthcare-related decisions and actions easy including guideline and CDS content developers, EHR vendors, other health IT suppliers, and many others.
In the future vision, knowledge assets (KAs) (e.g., individual clinical studies, systematic reviews, clinical recommendations, training materials, reference information, and many other information types) that these resource developers use in creating their offerings are FAIR, computable, and useful. For example, when manually seeking to find a KA or a group of KAs, resource developers can easily find the right KAs, all the right KAs, and nothing but the right KAs. In circumstances where the desire for the right KAs can be anticipated for the resource development task at hand (e.g., in keeping a clinical recommendation or CDS intervention up to date), the search and retrieval process is proactive, such as through precise, automated searches that notify developers when pertinent new literature is published.
Determination of right in the context of finding the right KAs is multifactorial with factors including relevance to knowledge application (e.g., PICO (41) specification of knowledge sought), certainty of the knowledge (e.g., quality of evidence or strength of the recommendation), compatibility with regulatory and contractual requirements (e.g., certification status, formulary availability), and the format for knowledge expression (e.g., PDF, links, executable code). Determination of right in the context of finding the right KAs is efficient because a person (e.g., a software engineer) seeking information can easily specify concepts of importance (e.g., the metadata dimensions that are tagged to facilitate search: PICO elements, certification status, creation date, artifact type, etc.) when searching. Search results are organized for further refinement based on these factors. Trusted experts and authorities have confirmed the accuracy of these factors, and they are communicated in universal standards for data exchange (to promote interoperability).
In the short-term future vision:

• Many of the KAs are manually discovered and assembled using search portals (see Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal and Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results)
• Common open-access points for finding KAs are available both online and through info buttons on health IT screens
• KAs can be filtered and sorted by relevance to appropriate audiences (e.g., patients or care teams)

Eventually, resource developers will have easy (ultimately automatic) access to updated, trusted KAs to inform the production of tools and resources that better address user needs.
In the longer term future vision:

• The assembly process is more automated, leveraging increasingly smaller component handling with granular resource tagging (PICO and other) and automatic identification as technology develops (AI, ML, NLP), and providing precise answers as easily as full documents
• APIs facilitate efficient identification of and access to comprehensive sets of KAs (including "push" notifications for emergent public health threats)
• Solutions provide context-sensitive support for user needs, with automatic population of resources in appropriate contexts, enhancing discovery and access (e.g., leveraging FAIR and computable KAs to support automated gathering of current recommendations and tools to prepopulate draft care plan templates for further processing by SMEs into care plan support tools that will be used by patients and care teams)
• AHRQ and other organizations better support development and updating of KAs and resources built from them because their offerings are validated (e.g., as meeting agreed-upon thresholds of methodological rigor and quality), tagged, packaged, disseminated, accessed, and applied more efficiently and effectively than is the case today
• Seamlessly integrated and interoperable virtual marketplaces enable resource developers and others to find, access, and reuse knowledge assets and tools efficiently
• Tools from resource developers are accompanied by analytics capabilities that provide data about resource use and impact, and this feedback informs continuous improvement in resource development and application, and helps generate new evidence to drive the virtuous LHS cycle

The Resource Developers' Future Vision is further described in the B.4.1, Detailed Resource Developers' Perspective of the ACTS Future Vision.

Detailed Resource Developers' Perspective of the ACTS Future Vision

Purpose of This Section

Achieving the Quintuple Aim (22) and the CDS 5 Rights (29) requires collaboration of all healthcare stakeholders and participants, including those who develop evidence-based guidelines and decision-support resources, as well as health IT suppliers such as EHR and population health management system vendors. This section frames the perspectives and future vision of these resource developers, defined as organizations that create evidence-informed tools and resources to support care delivery and care transformation.
This future vision illustrates how AHRQ-supported and other knowledge artifacts (KAs) (e.g., care plan templates, decision support tools, guideline recommendations, systematic reviews) can be better used to create, update, and deliver these offerings. The future vision addresses new ways evidence-informed resources and the KAs upon which they are based will be created, discovered, and used. In this future vision, resource developers could access AHRQ offerings and other information more efficiently and effectively than they do currently to produce and deliver the decision support interventions required to optimize care delivery and transformation.

Resource Developers' Future Vision Executive Summary

Suboptimal Current State

In the current state, resource developers seeking KAs to develop their care support tools and resources face tremendous inefficiencies, resulting in products not optimally suited to meeting user needs:

• KAs are scattered across hundreds of databases and websites
• Search solutions that cross hundreds of sources do not have limiters to identify validated and relevant KAs
• Many KAs of interest are not available via APIs (275)to directly support automated retrieval
• When multiple KAs are found, there is no easy method to distinguish duplication (repetition of the same knowledge in a different artifact) from replication (reproduction of results from additional information sources, a finding which increases certainty of the knowledge)
• When multiple KAs are found, there is no easy method to:
  • Determine consistency of knowledge across the KAs
  • Ascertain the certainty of knowledge within them
  • Compare and contrast these multiple KAs on the basis of any standards or quality assessment tools
• There is no consistent interface between KA sources and health IT systems to provide evidence to users in a timely, context-sensitive manner

Ideal Future Vision

In the future vision, these inefficiencies will be largely resolved and resource developers seeking KAs to develop or work with their care support resources will be instantly supported by the following improvements:

• When manually seeking to find a KA or a group of KAs, they can find the right KAs, all the right KAs, and nothing but the right KAs
• In circumstances where the desire for the right KAs can be anticipated, the search and retrieval process is automated and not dependent on manual triggers
• Determination of right in the context of finding the right KAs is multifactorial with factors including the following:
  • Relevance to knowledge application (e.g., PICO (41) specification of knowledge sought)
  • Certainty of the knowledge (e.g., quality of evidence or strength of the recommendation)
  • Compatibility with regulatory and contractual requirements (e.g., certification status, formulary availability)
  • The format for knowledge expression (e.g., PDF, links, executable code)
• Determination of right in the context of finding the right KAs is efficient because:
  • The person (or system) seeking information can easily specify concepts of importance when searching (the metadata dimensions that are tagged to facilitate search (e.g., PICO elements, certification status, creation date, artifact type, etc.)
  • Search results are organized for further refinement based on these factors
  • Trusted experts and authorities have confirmed the accuracy of these factors
  • Factors are communicated in universal standards for data exchange (to promote interoperability)

Current State

Resource developers provide disparate tools that support care plan development and execution, and otherwise support care delivery and care transformation; but they do so piecemeal, which is inefficient and does not optimally meet user needs (including quick and easy access). EHR and other health IT system content depends upon resources provided by guidelines and CDS developers, but those are currently limited, with inconsistent quality and poor discoverability, access, and navigation at the right time and place, especially at the point of care. As a result, implementation and adherence rates (276) (key drivers (277) for optimizing quality of care, clinical outcomes, and cost effectiveness) are low for current guideline recommendations and CDS artifacts.
The time lag between scientific discovery and integration of new knowledge into clinical practice resources remains challenging. Few clinical practice guidelines (CPGs) employ digital data with regular or continuous literature monitoring to keep the evidence base current and thereby provide recommendations that are persistently kept up to date. The same applies to other types of CDS tools. Health IT vendors are not able to classify how up to date various tools and resources they consume and produce are, much less have the capabilities to easily replace outdated ones with new versions.
AHRQ resources are intended to be useful for various audiences including evidence-based guideline developers, CDS providers, patients, healthcare professionals, and others; but there are limitations and barriers:

• The USPSTF guidelines address only prevention so guidelines addressing diagnosis, screening, staging, treatment, management, and other areas must be developed by organizations external to AHRQ. In the United States, these are primarily developed by medical professional societies.
• The National Guidelines Clearinghouse was terminated with no replacement yet authorized, eliminating a popular database for searching and identifying guidelines that meet explicit criteria. Similar considerations apply to the National Quality Measures Clearinghouse.
• EPCs are charged with conducting comprehensive systematic reviews. However, the EPC reports are long and not always as useful for guideline development as many medical professional societies may have hoped. They often do not address the specific PICO questions posed by the requesting organization, since other stakeholders are allowed to modify the PICO elements. It is difficult and time-consuming to update these reviews to keep the guidelines current.
• The concept behind the SRDR+ was intended to help guideline developers update the digital dataset as new evidence emerges, thereby supporting 'living guidelines' that are more easily kept up to date. But SRDR+ is mostly technology-focused and missing the services component, resulting in complex and tedious work for guideline developers. The medical professional societies do not have the staff or volunteer resources to extract the data into the digital environment and are not comfortable with sharing the data extracted by others, whose skills they do not know or trust.
• The AHRQ resources alone generally do not cover the full range of information most resource developers need because these resources usually cover only a limited set of topics and healthcare questions (that is, they don't address all the questions people face when making healthcare decisions). For example, a systematic review addressing the benefits and harms of a surgical procedure may not address recovery time or experience, which are common patient concerns. When the AHRQ resources do approach a topic comprehensively and holistically, the material may not be updated continuously so resource developers still need to search for new evidence, regulatory changes, or other information to have the most current, valid, and relevant content for real-time use.

Future Vision

Short-term Future Vision

The short-term future vision calls for a search portal to efficiently locate and identify knowledge artifacts matching search criteria facilitated by metadata tagging, including PICO and research design elements, and general knowledge artifact types.
Guideline developers will collaborate with CDS creators for guideline-based CDS and other knowledge artifacts. Computable and automatically updated recommendations and CDS resources will be tagged and uploaded into web-based platforms for all healthcare domains, resulting in a one-stop search/browse experience across repositories where these offerings are housed. User-friendly UIs will make it easier for resource developers to access information and tools they process into their offerings. This content will be discoverable through human-triggered, PICO-based searches.
Guideline recommendations and CDS resources will be developed in compliance with accepted standards to improve quality and reduce redundancy. In the case of multiple guideline recommendations or CDS tools addressing the same clinical topic area, there will be a comparison tool based on appropriate criteria for validity, relevance, and trust (e.g., recency of publication, quality of the underlying evidence, geographical target audience, and standards for recommendations, such as some of the latest Appraisal of Guidelines for Research and Evaluation (AGREE) instruments (278) for assessing the quality of guidelines) but also a way to identify consistency or inconsistency when multiple recommendations or tools are relevant and sufficiently valid.
Governance and enforcement of inclusion and exclusion criteria in portals that provide access to vetted content will ensure end-user confidence in retrieved results. For example, validating that structure and content standards are followed confirms that the methodological rigor is sufficient and the KAs are evidence-based; thus, users will be able to trust the quality of the tools and resources. This governance will, therefore, require assessments of adherence to accepted methodological standards. Governance will address intellectual property (IP) rights and subscription-based access. If a KA is not freely provided, pay-per-view or subscription purchase will be options.
Development of user-friendly interfaces is paramount to the short- and long-term success of embedded CDS. CDS creators, EHR/health IT developers, and end users will work together, on a continuous basis, to develop and refine tools which provide context-sensitive, actionable recommendations to patients and their care teams in real time through pertinent information systems (e.g., EHRs, patient portals) with minimal disruption to respective workflows.
The portal (see Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal, Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results, and Figure B-3. Care Plan Support Tool Mockup Interface) to make evidence-based resources and knowledge findable and accessible to all stakeholders will be adaptable to meet the needs of different stakeholders. For resource developers, this means the ability to specify the types of knowledge they seek, including both resources designed for end users and those providing "raw materials" that resource developers use to create new tools and products. This also means supporting API access to the portal so that resource developers can create sophisticated and automated methods to search for their needs, including on-demand and continuous search to alert them to new knowledge.
Because resource developers are themselves creating resources to be FAIR (59), it will be most efficient if the resources and "raw materials" they find are poised to be interoperable. In the healthcare domain, the predominant standard for data exchange is FHIR (279). FHIR itself is being extended to support data exchanged for biomedical evidence and statistics with the creation of FHIR Evidence Resources (146). Knowledge resources that contain evidence and statistics can be stored in computable form (that is, the evidence and statistics can be expressed in machine-interpretable granular specifications defined as FHIR Evidence Resources (280)). Knowledge resources that contain executable code (that is, knowledge resources that include UIs or expressions for how data should be processed and displayed) will be provided in SMART (281) frameworks that support interoperable use across electronic health systems.

The Longer Term Future Vision

In both the short- and long-term visions, technology will support user-generated information requests. But only in the long-term vision will automated information automatically populate the right information and tools directly into the pertinent information system when triggered by appropriate PICO preference selections for the offering under development. Resources developed to inform and support care delivery need to be developed as precisely as possible and in an automated manner to be implemented by healthcare professionals, patients, and care teams. This is a fundamental goal for all resource developers as they aim for their products to be relevant, context-sensitive, and automatically displayed at the right times, in the right places, for the right users, in the right formats, and on the right channels (information systems/places, at the right point in the workflow). The longer term vision defines more granular components of these knowledge artifacts (e.g., logic rules, recommendations, evidence assertions) for computable expression. AI and/or machine learning (ML) will assist in the production and use of a large collection of searchable, reusable knowledge. Where ML/AI is unable to achieve the goal directly, the care resource developer may use ML/AI to facilitate human curation for achievement of this goal. The key ingredients in the care delivery future vision are integrated, patient-centered care plans that are generated from templates that preassemble and integrate evidence-informed guidance, tools, and resources to address the patient's clinical issues (including preventive care), individually and collectively. (see Figure B-1. Mock Portal Example 1—EvidenceInformed Resource Portal, Figure B-2. Mock Portal Example 2—EvidenceInformed Resource Portal Results, and Figure B-3. Care Plan Support Tool Mockup Interface). Resource developers will need to produce "care plan generators" that provide templates for condition-specific management plans and tools for combining and customizing them for patient-specific goals, preferences, and circumstances. These care plan generators (and related tools for supporting evidence-informed decisions and actions by all those giving, supporting, and receiving care) will be generated in ways that they can proactively and automatically populate EHR/PHR screens through AI/ML retrieval when triggered by related PICO concepts and/or patient preference terms. These tools will comprehensively address prevention, screening, diagnosis, treatment, and management for acute and chronic conditions, as well as commonly occurring constellations of multiple conditions. They will be able to display the relevant guideline recommendations, CDS tools, and underlying sources. They will also be linked to tracking mechanisms so that intervention effects can be determined. Content will be AI/ML supported to pull all appropriate KAs for display with descriptive information. PICO annotation will drive the underlying identification and tagging of KAs to matching search queries or for automatic population. All clinical taxonomies (Systematized Nomenclature of Medicine \[SNOMED\], Medical Subject Headings \[MeSH\], National Cancer Institute Thesaurus \[NCIT\], International Classification of Diseases, Tenth Revision, Clinical Modification \[ICD-10\], Current Procedural Terminology \[CPT\], etc.) will be mapped so that a single term or concept will pull all synonyms. The software would continue to "learn" as it is used. To help those working to transform care with gathering and applying pertinent information and tools, resource developers will provide a new generation of care transformation support resources. These offerings will help QI teams identify, access, and use the resources to manage entire QI initiatives or address particular components of such initiatives (e.g., configuring health IT tools to support the target or gaining stakeholder engagement in the improvement effort). These care transformation support resources are analogous to the care plan generators in that they precompile high-quality, evidence-informed resources so that they can be accessed and applied more efficiently and effectively to achieve complex goals. The knowledge management tools mentioned above that resource developers use to create their offerings—together with other LHS ecosystem enhancements described elsewhere in this Roadmap—will support resource developers in creating these care plan generators and related tools. Decision support tools will be interoperable across settings and information systems. For example, care teams will share evidence-based decision algorithms, treatment decisions, and care plans across EHR platforms and vendors. Similarly, sharing of questionnaires and completed decision aids will be possible between care teams and patients, EHRs and PHRs, and across other health IT platforms. Resource developers will provide capabilities to generate analytics at a high level for the short-term platform usage but at a much more granular level within the longer term vision in the health IT system (e.g., EHR or PHR/patient portal). To generate insights that contribute to an LHS, systems will monitor, report, and support analyses on:

• The frequency with which users consult specific recommendations
• The frequency with which users adhere to the recommendations
• The likelihood that the recommendation had an impact on the patient outcome (e.g., via by EHR vendors' enhanced capabilities to better track outcomes as they evolve to include enhanced-support LHSs)

As in the near-term future vision, governance and enforcement of inclusion criteria will be necessary to ensure end user trust, enforcement of standards, and the ability to assess the quality of the tools and resources. Methods and process standards will be judged based on established rules to ensure methodological rigor and that the quality meets accepted standards. These may change over time as real-world evidence becomes more usable in precision medicine and as technologies provide greater analytic capabilities. The governing bodies will need to lead these advancements in the field and support educational awareness and knowledge.
Governance will also maintain intellectual property (IP) rights, but subscription-based access—when KAs are not freely available—will be discouraged so that all relevant resources become freely available to all end users.
Figure B-4. Ecosystem of Resource Development & Feedback is an overview of how inputs to and outputs from resource developers will help deliver the future state for care delivery.

AHRQ & Other Assets to Support the Future Vision

AHRQ resources will become more valuable and useful for resource developers.
The SRDR+ should be serviced only by the trusted methodologists of the EPCs basing the extractions on the relevant PICO elements and other data configuration specifications. Software to aid search, screening, and extraction will be employed to reduce errors and increase efficiencies, while maintaining a focus on accuracy. The extracted data can then be trusted and shared by all users. All methods and processes will be documented in the metadata, including any calculations created or results converted. The digital dataset can be expanded as new research is published, pooling all relevant data for updated analyses, again by trusted EPC methodologists. Previous results can be compared with new results using the same saved workflows. Literature should be monitored regularly and guideline developers alerted when new trial data are published that matches the PICO elements of interest. This can be facilitated by PICO-annotation of the new publications and by AI-identified elements of relevance.
Methodologists would write less of a report and more of an explanation of what each of the analyses reveal, including strengths and limitations in that specific body of evidence. The descriptive explanations of the analytic results would be tagged by PICO element and appear with the results of the meta-analyses or network meta-analyses. Subsequent cohort or sensitivity analyses could be commissioned and would also be accompanied by quality interpretations. Personographs and other data visualizations will be produced for each meta-analysis with the ability for customization. All of this content would be accessible through a PICO-based search of the contents of the SRDR+.
The recommendations that are produced by guideline developers, including those of the USPSTF, would become granular knowledge artifacts that CDS developers use to create tools for shared decision-making. This content (including USPSTF, CDS Connect, other guideline recommendations, and other CDS resources) will be context-specific for patients, physicians and other healthcare professionals, and care managers. The content will be uploaded into a freely available, user-friendly, and easily searchable repository, possibly available through an existing source (e.g., PubMed or Google) or a new source. They will be tagged by the patient characteristics, interventions, and outcomes upon which they were created, and will be associated with the supporting evidence, analyses, EPC explanations or reports, references, and other relevant content, as listed above. Links to FDA alerts, drug labels (kept up to date by regulatory feeds), and reimbursement codes should be tagged to surface for PICO-relevant content.
API methods for CDS suppliers and others to search and receive AHRQ and others' knowledge artifacts should include assignments to permanent URLs and easy-to-copy reference citations. Tagging the knowledge itself (in addition to the knowledge artifacts) would require tagging the many specific concepts like terms, phrases, statistics, and the many relations across the terms, phrases, and statistics. Eventually, AI techniques might help make this less labor-intensive. This can be facilitated by ontology mapping of all clinical taxonomies to surface all synonyms with single search terms for each concept. All parties would have to use the same standards and systems, such as the current effort to produce a global standard for computable expression of evidence and statistics, known as the HL7 FHIR Resources for EBM Knowledge Assets project (EBMonFHIR) (146).
AHRQ will play an active role in closing the feedback loop by monitoring the usefulness and impact of clinical recommendations. The interface between physicians using embedded CDS and guideline developers analyzing the impact of the recommendations will facilitate the development of evidence-generating medicine as an essential component of the LHS.
All users will have free online access to this master index for all of healthcare, therefore becoming the single best resource to access this content, regardless of which organizations (AHRQ or others) developed the various knowledge artifacts and tools. Eventually, they will surface in the EHR and other health IT screens when appropriate keywords or concepts appear in the proper combinations. Additional resources will also be available through convenient links for users who want to explore these or drill into the underlying evidence. (Refer to the Care Delivery Perspective of the ACTS Future Vision for more details.)

Additional Considerations for AHRQ

It took IOM, now the National Academy of Medicine (NAM), standards to have a significant impact on adopting more evidence-based and standardization methods and processes. It might take a similar high-profile effort to facilitate some of these recommended changes. Furthermore, there should eventually be methodologies that support precision medicine with customized recommendations based on aggregated real-world evidence, but the IOM standards do not currently support these processes. AHRQ should consider sponsoring a new NAM committee to review and update the former standards, within the context of advances in technologies, translation sciences, and precision medicine.

LHS Perspective of the ACTS Future Vision

Organizational LHS Future Vision Perspective

CDO CQI teams have ready access to—and efficiently leverage—tools and resources that help them engage local stakeholders and take other steps needed to continuously improve care delivery processes and outcomes Details presented here focus on LHS, CQI, and QI for individual CDOs and organizations that support this work, not the broader ecosystem.. These tools and resources are informed by best evidence and practices, address costs, are sensitive to local needs, and support target-focused QI efforts as well as broader organizational care transformation/LHS initiatives. For example, a new generation of care transformation support toolkit (analogous to "Care Plan Support Tool") helps QI teams access and apply tools pertinent to their particular CQI needs. This toolkit makes it easier to identify, select, access, and use QI tools from AHRQ and others (e.g., such as those samples in Table B-7. Current AHRQ (& Other) Resources for LHSs in the more detailed the Organizational LHS Ideal Future Vision.
These tools and resources are applied in a context where CQI goals and processes are an organizational mission priority, led and supported by executives and clinical champions and embedded in an interprofessional learning culture that nurtures workforce and talent development, fosters joy and meaning in practice, and achieves an LHS. Organizational and regulatory requirements are harmonized to support optimal care, reduce administrative burden, and drive progress toward the Quintuple Aim.
The Organizational LHS Ideal Future Vision is further described in B.5.3, Detailed LHS Perspective of the ACTS Future Vision.

National LHS Future Vision Perspective

The national LHS will fully "harness the power of data and analytics to learn from every patient and feed the knowledge of 'what works best' back to clinicians, public health professionals, patients, and other stakeholders to create cycles of continuous improvement." (282) Measurable improvements in the Quintuple Aim are achieved through widespread implementation of LHS organizations that:

• Have leaders who are committed to a culture of continuous learning and improvement (283)
• Systematically gather and apply evidence in real-time to guide care
• Employ IT to share new evidence with clinicians to improve decision making (i.e., as outlined in the B.3. Care Delivery Perspective of the ACTS Future Vision)
• Promote the inclusion of patients as vital members of the learning team
• Capture and analyze data and care experiences to improve care
• Continually assess outcomes, refine processes, and conduct training to create a feedback cycle for learning and improvement

This future is facilitated and propelled by leadership and collaboration at a national scale that works to facilitate and ensure the conditions that allow LHSs to emerge and thrive. These stakeholders reduce organizational and professional burden by harmonizing expectations and incentives to optimize continuous learning and improvement across diverse healthcare settings. They bring together diverse stakeholders to align and optimize data and technology approaches that fuel LHS insights locally and as part of a national community of practice. The culture of healthcare improvement shifts toward meaning and joy buoyed by data-informed continuous learning.
The flow of information, tools, and resources around the LHS cycle creates a virtuous cycle that continuously improves processes and results and achieves the Quintuple Aim. Payment drivers and policies support this and foster full realization of the other future vision perspectives. In an ideal future state, national approaches will include:

• Harmonization of organizational and professional regulatory requirements for CQI, performance management, use of targeted real-time data, and continuous learning to reduce administrative burden and drive progress toward the Quintuple Aim
• Policy, collaboration, and funding approaches to spur elaboration, endorsement, and implementation of LHS key principles (e.g., LHS Core Values (284), LHS competencies for researchers (285)) that make possible an interconnected community of practice
• Evolution of accountability frameworks, measures, and payment approaches from individuals toward accountable teams and systems (190) (286) (287)
• Engagement with organizations and stakeholders that lead and inform continuous organizational and workforce learning (e.g., workforce development, performance management, accredited continuing education, teaming, talent development)
• Other supports that enable fully realizing the future visions outlined for the other three future perspectives

The National LHS Ideal Future Vision is further described in B.5.3, Detailed LHS Perspective of the ACTS Future Vision.

Detailed LHS Perspective of the ACTS Future Vision

Introduction and Purpose

This section outlines the fundamental role that continuous learning plays in healthcare improvement. The future vision perspective described here, where continuous learning is an essential catalyst for achieving the Quintuple Aim (22), requires two frames of reference—a national LHS scale and an organizational LHS scale (i.e., CDO). This section describes the current state and envisioned future state from each of these perspectives. The authors have included this dichotomy together to recognize the active and interdependent relationships of data, knowledge, and practice within and between healthcare organizations that fuel continuous learning and improvement for all.
AHRQ defines an LHS as, "a health system in which internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice." (283) As a result, patients get higher quality, safer, more efficient care, and healthcare delivery organizations become better places to work." The idea was first conceptualized in a 2006 workshop (288) organized by the U.S. IOM, and progressively developed through several convenings, publications, and ongoing initiatives. For a historical review of the development of LHSs, see the 2018 article from Rubin, et al. in Learning Health Systems Open Access (349). In 2011, the IOM's (now the National Academy of Medicine) Digital Learning Collaborative described a shared value framework for both the national and organizational LHS perspective in which, "progress in science, informatics, and care culture align to generate new knowledge as an ongoing, natural by-product of the care experience, and seamlessly refine and deliver best practices for continuous improvement in health and healthcare." (289)
In this vision, organizations—as LHSs—embody a "cyber-social system of people and technology" (290) that supports iterative learning cycles that turn data into knowledge that informs practice and generates data from practice that creates new knowledge, and so on. In this publication, Charles Friedman et al. explain that, "Learning cycles can occur at varying levels of scale. They can be undertaken by a single organization, by networks of otherwise independent organizations, by specialized disciplines that span organizational, legal, and geographic boundaries, and across geographical regions varying in size, from counties to states/provinces to entire nations. Because the actions necessary to execute learning cycles are, to a significant degree of approximation, invariant across these levels of scale, LHSs exhibit important fractal-like properties of self-similarity. The infrastructure supporting LHSs is capable of delivering the same services at any level of scale." Therefore, at a national scale, a community of many LHSs create opportunities to harness the large-scale creation and utilization of data to and from practice to support continuous learning and healthcare improvement within and across CDOs.
With this described framework, LHS approaches encompass activities which may be labeled "care transformation." These include (e.g., redesigning care delivery processes broadly to achieve outcomes more aligned with the Quintuple Aim Improving quality of care, cost of care, patient experience, and provider experience. (22) (23)), Redesigning care processes may be target-focused QI (e.g., redesigning care processes to improve a particular performance measure over a focused time period), or CQI where targeted improvement efforts are managed as an ongoing rather than time-limited initiatives.
However, the LHS methodology is to advance the efficiency and sustainability of continuous improvement by building systematic capability for learning, itself. The LHS future, then, is a catalyst for bringing the Roadmap's Care Delivery Perspective of the ACTS Future Vision (improving the efficiency, efficacy, and experience of care team work) and the Resource Developers' Perspective of the ACTS Future Vision (advancing the utility of data and data systems to improve care) to fruition in a local and national context. Through LHS approaches, organizations identify, customize, and optimize improvement tools and processes that meet their unique needs. In the context of their own environments, learning activities produce data and are informed by that data, and they are collaboratively studied and honed (at different scales) so that they can become more effective and efficient in promoting change. When LHSs operate at a national system scale, their data, insights, and methods accelerate the community's learning which, in turn, elevates learning at the organizations. These fruits not only include optimization of improvement-related tools and resources, but engagement of the healthcare workforce in collaborative leadership (for improvement) that builds meaning.

Organizational LHS Perspective Current State

Although CDOs and the healthcare workforce is widely engaged in some manner of QI (i.e., CQI) efforts, only a small number of healthcare organizations are pursuing LHS approaches (i.e., leadership-led culture of learning, producing/consuming data to/from practice to inform CQI, embedded expertise to support continuous learning).
Precisely because CDOs and support organizations are pursuing so many different approaches for care transformation, most are unable to allocate time and resources to take a reflective and data-informed organization-wide approach to learning from their own care delivery performance. They are surrounded by data from practice and outcomes of care but lack the means to derive meaning from that data that can inform continuous improvement. The result is preventable harm and an inability to address care quality in a substantive way.
Healthcare policy, payment, and accountability approaches do not favor collaborative, interprofessional learning and improvement at an organization, practice, and team level.
As described in the Roadmap report, the journey toward value-based care currently includes a number of obstacles to interprofessional collaborative practice, let alone interprofessional practice-based learning. Within CDOs, efforts to support documentation for billing and reimbursement take time and resources away from patients, but prevent the broader healthcare workforce from
The environment of myriad regulatory and professional expectations for organizations and clinicians/care teams, respectively, to participate in CQI (including clinical performance improvement) is a major driver of clinician burnout. (291)
Workforce burnout—defined as, "a syndrome characterized by emotional exhaustion that results in depersonalization and decreased personal accomplishment at work"—is an increasingly recognized problem resulting from the complex demands on clinicians. "The emotionally exhausted clinician is overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others." Aside from the deleterious effect burnout has on health professionals, it has been shown to adversely affect the quality of care and patient safety (292). The abundance and complexity of quality- and performance-related expectations has also resulted in a significant (if unintended) quagmire of administrative burdens that CDOs and their workforce must bear (e.g., organizational requirements from CMS and the Joint Commission, professional requirements such as Continuing Board Certification, aka MOC). Further, the lack of meaningful clinician engagement and leadership in CQI processes is an identified factor (283) that places the Quintuple Aim out of reach in the current state.
Improvement tools and resources are underused because there is little or absent infrastructure (i.e., time, people, resources) that can make them usable and effective to address the local "real life" contexts of individual CDOs.
A growing number of tools, resources, and platforms have been advanced by AHRQ and others (see Table B-7. Current AHRQ (& Other) Resources for LHSs) to support LHS values (i.e., CQI and care transformation) via national, organizational, and team/individual approaches. These resources range from broad, capacity-building workforce development curricula (e.g., TeamStepps (293)) to embedded practice-based products (CAHPS® Clinician & Group Survey (294)) to data-sharing frameworks to support clinical decision making (CDS Connect (98)). These programs include collaborative approaches for convening, funding, and fostering limited communities-of-practice for organizations and individuals utilizing these tools.
To make use of this catalog of different tools and resources, individual CDOs must:

• Navigate multiple, variegated sources for tools and resources
• Possess staff time/expertise to identify those resources that meet their needs (broadly stated)
• Be able to customize those tools/resources to their setting and specific needs
• Have resources to lead or coach others on resource/tool implementation
• Measure/reflect on the impact that the tool/resource is having on clinical performance/care outcomes in order to identify opportunities for improvement

Considering these steps within a single organization, let alone across multiple organizations, it is apparent that the resources currently required to identify, customize, and manage the implementation of multiple CQI/care transformation tools are significant, if not out of reach. Putatively, this may contribute to poor or variable utilization of these tools across CDOs.
LHS leaders, core values, and an incipient community of practice (291) provide an encouraging vision of the future but are insufficiently distributed and supported to lead substantive change for the larger healthcare system.
LHS visionaries and practitioners have been working together for more than 10 years to create a framework for LHS implementation. In recent years, these efforts have yielded LHS researcher core competencies (295), core values (296), collaborative implementation initiatives (e.g., LHS Centers of Excellence (297)), and case studies (298). The University of Michigan oversees an open-source Learning Health Systems journal (299), edited by Dr. Charles Friedman, who helped explore the concept of LHSs in 2010 through IOM while at the ONC. International efforts in support of LHS implementation include the Learning Healthcare Project (UK) (300) and the Swiss LHS (301).
U.S. efforts have laid the groundwork for domestic LHS implementation, but the national and local organizational resources required for broad implementation are not yet in place. The current state observations in this appendix are, collectively, the evidence of the obstacles that separate LHS aspirations from widespread implementation.

Organizational LHS Ideal Future Vision

In an ideal future state, CDOs and their partners will endorse and implement LHS core values (284). Design and operation of LHSs are derived from the following core values (296):

1. Person-Focused: The LHS will protect and improve the health of individuals by informing choices about health and healthcare. The LHS will do this by enabling strategies that engage individuals, families, groups, communities, and the general population, as well as the U.S. healthcare system as a whole.
2. Privacy: The LHS will protect the privacy, confidentiality, and security of all data to enable responsible sharing of data, information, and knowledge, as well as to build trust among all stakeholders.
3. Inclusiveness: Every individual and organization committed to improving the health of individuals, communities, and diverse populations, who abides by the governance of the LHS, is invited and encouraged to participate.
4. Transparency: With a commitment to integrity, all aspects of LHS operations will be open and transparent to safeguard and deepen the trust of all stakeholders in the system, as well as to foster accountability.
5. Accessibility: All should benefit from the public good derived from the LHS. Therefore, the LHS should be available and should deliver value to all, while encouraging and incentivizing broad and sustained participation.
6. Adaptability: The LHS will be designed to enable iterative, rapid adaptation and incremental evolution to meet current and future needs of stakeholders.
7. Governance: The LHS will have that governance which is necessary to support its sustainable operation, to set required standards, to build and maintain trust on the part of all stakeholders, and to stimulate ongoing innovation.
8. Cooperative and Participatory Leadership: The leadership of the LHS will be a multistakeholder collaboration across the public and private sectors including patients, consumers, caregivers, and families, in addition to other stakeholders. Diverse communities and populations will be represented. Bold leadership and strong user participation are essential keys to unlocking the potential of the LHS.
9. Scientific Integrity: The LHS and its participants will share a commitment to the most rigorous application of science to ensure the validity and credibility of findings, and the open sharing and integration of new knowledge in a timely and responsible manner.
10. Value: The LHS will support learning activities that can serve to optimize both the quality and affordability of healthcare. The LHS will be efficient and seek to minimize financial, logistical, and other burdens associated with participation.

CDOs will use an LHS to implement a leadership-instilled learning culture.
With an institution-wide learning culture that is led from the top, CQI will be synonymous with institutional mission-priorities and harmonized with workforce development, performance management, and a caring approach to patients and communities.
The ranks of improvement personnel will be expanded to include all organizational stakeholders, from the healthcare workforce to patients with lived experience, families, and community-based public representatives.
The learning culture will value and engage clinicians and interprofessional teams in collaborative leadership of continuous learning and improvement that fosters joy and meaning in practice.
CDOs will invest in human capital (e.g., learning/change-management professionals, researchers) that lead and facilitate continuous learning and improvement.
To address the gaps of translating knowledge to practice and producing knowledge from practice, organizations will dedicate resources to build organizational competency for continuous learning and change management. These approaches will include:

• Recruitment, training, and professional development of learning professionals who can work collaboratively and interprofessionally to identify/select, inform, and coach individuals, teams and systems on the use and customization of LHS implementation resources (e.g., care transformation support tools) in the context of workforce development, talent development, and performance management
• IT personnel to lead/support access to, and optimization of, LHS implementation resources
• Researchers who help their organization reflect on its own performance/improvement and create knowledge from practice that can be shared with other LHSs

CDOs will achieve real-time and near real-time data collection and analysis that informs continuous learning and improvement.
LHSs use health IT tools and resources as both producers and consumers of local (and collected national) data from practice that informs learning and improvement in practice. These approaches include:

• Benchmarking using a variety of data sources (own system, other like systems, regional, U.S., commercial, and CMS claims)
• Information is easy to see and digest to allow rapid pivots in LHS learning cycles, and modification to data collection elements accommodates rapid pivots
• Data collection and analysis methods result in decreased workforce burden and an increase in targeted, actionable, patient-centered improvements

The LHS will have care transformation support tools that provide the means to leverage national and local/institutional LHS knowledge to achieve practice-based improvement that is both informed by evidence and customized to local settings.
At the institution level, access to enhanced technology tools (e.g., a dynamic portal to access/apply care transformation tools and resources) will buoy continuous learning and improvement efforts. These resources will support the work of the improvement workforce (including patients and communities) by providing solutions that are informed by evidence but customizable to local practice settings. With key information/elements that are customizable for each local institution's needs/setting, these tools will be developed from, and continuously shaped by, the learning cycle(s) of LHSs locally and nationally.
CDOs will observe increased efficiency in improvement efforts, improved outcomes, and lower workforce burnout due to integration of continuous learning into every aspect of system processes.
Via a learning culture and dedicated resources to support its implementation, organizations will have ready access to measures of their own progress as an LHS by which to benchmark and validate the business case (i.e., ROI) for investing in LHS approaches.

National LHS Perspective Current State

There is no shared vision broadly adopted across all key stakeholder groups about what the various national LHS components should look like to help focus efforts.
LHS core values (296), leadership and process features, workforce competencies (for research professionals), and frameworks for computable biomedical knowledge have been defined, elaborated, and adopted by a nascent LHS community of practice. However, these approaches have not been formally adopted nor prioritized and resourced for implementation broadly at the national level.
There is no universally adopted mechanism for coordinating the many efforts focused on achieving LHS results in unhelpful redundancies, inefficiency, and suboptimal progress toward goals.
The framework for LHS implementation at a national level requires active collaboration among multiple stakeholders to enable standards and processes for data interoperability, research, and learning.
It is difficult for participants around the cycle to find, access, and implement useful information, resources, and tools.
Spread across many disparate/isolated systems and not packaged and organized in ways where they can be mapped to specific needs, existing information, resources, and tools are not represented in a standardized fashion to facilitate identification and application, nor are they evaluated adequately to support evidence-based use.
Continuous learning is not prioritized as a healthcare workforce imperative.
This and other challenges result in slow progress addressing suboptimal healthcare outcomes.

National LHS Ideal Future Vision

In the ideal future state, national LHS approaches will result in continuous improvement in Quintuple Aim outcomes. Continuous learning healthcare will provide information/evidence and resource flow resulting in efficient and rewarding processes and desired outcomes for participants at all points around the LHS cycle.
An LHS will harmonize policies and incentives from payers, regulatory bodies, and others to support a virtuous LHS cycle.
Harmonization of organizational and professional regulatory requirements for CQI and clinical performance and alignment of payment incentives to value-based care (i.e., targeted, real-time performance/outcome measures that build a learning and improvement dataset) reduce administrative burden for organizations and their healthcare workforce. As a result, organizations turn their time and effort toward LHS approaches that drive progress toward the Quintuple Aim. Regulatory bodies and policymakers continue their vigilance to reduce or eliminate unhelpful siloes and fragmented efforts, information, tools, and resources.
Having an LHS will be a national healthcare priority for policymakers, collaborative agencies, and Federal and foundational funders.
Policy leadership, collaboration, and funding approaches spur elaboration, endorsement, and implementation of LHS key principles (e.g., LHS core values (284), LHS competencies for researchers (285)) that make an interconnected community of practice possible.
An LHS will prioritize inter- and intraorganizational continuous learning and improvement as a workforce imperative.
Organizations and stakeholders that lead and inform continuous organizational and workforce learning (e.g., workforce development, performance management, accredited continuing education, teaming, and talent development) will support the local and national needs of LHSs.
Using an LHS will facilitate easy access to optimal tools/resources for continuous learning and improvement.
Optimal tools/resources for continuous learning and improvement may have the following characteristics:

• Provision of key information and simplified categorization (i.e., "tagging") that allows end users to compare and contrast different tools and resources on the basis of resources required to implement, infrastructure requirements, workforce training requirements, etc.
• Alignment with harmonized regulatory and professional expectations (e.g., process improvement and outcome metrics are neatly aligned with endorsed measures such as NQF, CMS Quality Measures and Improvement Activities, NCQA, Hedis, etc.; CQI interventions clearly aligned with improvement outcomes: morbidity, mortality, opioid CDS aligned with opioid-related death and adverse drug events, ED/hospitalization metrics)
• Users/consumers have access to optimal LHS implementation tools/resources when, where, and how they are needed to optimize decisions, actions, and outcomes (e.g., offerings adhere to standards and are curated and accessible via integrated portals and marketplaces)

Assets Currently Available Related to Future Vision

Table B-7. Current AHRQ (& Other) Resources for LHSs includes a list of resources and tools currently available to support the care transformation (i.e., CQI) work of CDOs, support organizations, and QI professionals.

Additional Considerations for AHRQ

Addressing the human capital aspects of LHS implementation may benefit from engagement with those organizations, professionals and other stakeholders that foster learning and improvement for individuals, teams, and organizations within (and external to) the healthcare sector. These potential partners may be drawn from the following domains:

• Healthcare Workforce Development—overarching strategies for the recruitment, training, continuous development, and retention of those people who work within healthcare organizations
• Talent Development—building the knowledge, skills, and abilities of others and helping them develop and achieve their potential so that the organizations they work for can succeed and grow
• Performance Management—a shared understanding, framework, processes, and measures that support continuous learning and improvement of individuals and teams
• Continuous Professional Development (CPD)—the learning journey of the healthcare professional as they seek to improve their competence and expertise, supported by continuing medical education and other personal/professional activities by the learner with the intention of providing safe, legal, and high-quality services aiming at better health outcomes for patients and communities
• Accredited Continuing (Medical) Education (CE/CME)—the process by which healthcare professionals engage in activities designed to support their continuing professional development with learner-centered activities that support their ability to provide high-quality, comprehensive, and continuous patient care and service to the public or their profession with content derived from multiple instructional domains focused not only on providing clinical care but also on developing those attitudes/skills necessary for the individual to contribute as an effective administrator, teacher, researcher, and team member in the healthcare system
• Interprofessional continuing education (IPCE)—members from two or more professions learning with, from, and about each other to enable effective collaboration and improve health outcomes