Robert J. Reid

Background: The Learning Health System (LHS) concept holds significant promise for continuous, data‐driven improvement in healthcare, yet operationalization at scale remains elusive. LHS maturity can be conceptualized as the extent to which organizations demonstrate essential capabilities. Current tools to assess LHS maturity have limited scope, and a rapid, multi‐stakeholder tool to assess organizational‐level LHS maturity remains lacking. Methods: To address this gap, we developed a maturity self‐assessment tool mapped to the LHS Action Framework by Reid and colleagues that operationalizes LHS maturity as capability levels across five core learning activities and selected infrastructure supports. Using design science and participatory action research, we conducted five sequential development steps: (1) item bank creation, (2) prioritization and refinement by the core research team, (3) expert panel review, (4) cognitive interviews with interprofessional decision‐makers, and (5) pilot testing in a real‐world setting. Each step incorporated participant feedback to refine and streamline the tool. Results: The resulting tool consists of 41 items assessing the extent to which LHS activities occur across the LHS Action Framework's five learning activities and supporting infrastructure. Preliminary findings from a national Emergency Department LHS assessment ( n = 53 responses from 33 sites) demonstrated the tool's feasibility and acceptability in a real‐world setting, and its ability to identify capability gaps across the LHS Action Framework's constructs. Conclusions: The self‐assessment tool provides a foundational measurement approach to guide LHS development, representing a critical step toward developing a comprehensive LHS maturity model. By facilitating a shared understanding of the LHS and enabling self‐assessment of the current‐state capabilities as core LHS maturity indicators, the tool may support evidence‐informed and collaborative strategic planning for a variety of health system configurations. Future research should evaluate the tool's generalizability across diverse contexts and utility for tracking developmental progress over time.

BACKGROUND Developing digital health solutions for complex health service environments poses a unique design challenge. Service models, like transitions from hospital-to-home for older adults with complex care needs, represent dynamic contexts in which multiple user types are working across diverse settings and workflows. Designing digital health solutions for these types of environments requires advancing traditional methods intended to design for the needs of single user groups working in more bounded settings. OBJECTIVE This study addresses this design challenge by combing Design Thinking and co-design methods to develop a digitally enabled hospital-to-home communication platform to meet the needs of older adult patients with complex care needs, their caregivers and hospital and primary care clinicians who are involved in the transition process. To co-design the Digital Bridge tool, the study was guided by two questions addressed in this paper: 1) How can we translate diverse user groups’ needs into technology features? And 2) Can incorporating a Design Thinking-driven process as part of user-centred co-design help to manage tensions with diverse user groups perspectives? METHODS The Institute of Design at Stanford’s Design Thinking approach (empathize, define, ideate, prototype and test) was applied to guide co-design of the tool; leveraging multiple virtual platforms (e.g. Zoom, Jamboards, journey maps), research methods (e.g. interviews, working groups, asynchronous feedback, surveys), and informatics tools (e.g. information flow and business process maps). Working groups consisting of patients and caregivers, hospital and primary care clinicians, and the project’s Citizen Advisory Committee. Working groups engaged in multiple-iterative design phases with the research and design team to adapt two existing technologies into the new Digital Bridge platform. RESULTS Pre-design work involving interviews with patients and caregivers identified nine challenges in the hospital-to-home transition process, including communication barriers, feeling rushed and invisible, and not knowing where to go when help was needed. Challenges acted as design anchors, guiding a series of five working group sessions with patients and caregivers (n=9), five working group sessions with hospital (acute and rehab sites) and primary care clinicians (n=28) and a round of surveys. Needs were mapped onto six tangible design functions and integrated in two separate technology platforms to align to the local digital ecosystems and workflows at two hospitals networks in Canada. Working across user groups, tensions around language and workflow surfaced and were addressed by prioritizing the patient- and caregiver-identified challenges, while maintaining a person-centred lens. CONCLUSIONS The Design Thinking approach was useful in guiding the co-design process, however, effective collaboration across diverse user groups required iterative rather than linear movement between stages of the Design Thinking approach. Future co-design projects working across diverse groups should consider embedding shared-empathy activities to manage tensions and develop true person-centred solutions. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT RR2-10.2196/20220

Background: Patients and caregivers are expected to engage in work that involves both physical and cognitive tasks to manage their care and well‐being during hospital‐to‐home transitions. Patient and caregiver work is defined as the health‐related tasks they must manage, as well as the physical and cognitive effort required to complete those tasks. When continuity of care is well‐supported, work for patients and caregivers may be reduced or better managed. However, there is a need to better understand how continuity of care affects patients' and caregivers' work to optimise their outcomes. Objective: To explore the work undertaken by patients and caregivers during hospital‐to‐home transitions in Ontario, Canada, and examine how different dimensions of continuity impact this work. Design: This qualitative interpretive description study engaged older adults (60+) who self‐reported complex care needs and had ≥ 1 hospital‐to‐home care transition, and caregivers supporting these transitions in a semi‐structured, audio‐recorded interview. A framework analysis integrating inductive and deductive coding, based on Patient Work and Continuity of Care models, was used to analyse the data. Results: Ten participants were interviewed: four caregivers, five patients and one individual who identified as both patient and caregiver. Two themes were generated: (1) physical and cognitive work performed by patients and caregivers during hospital‐to‐home transitions, and (2) how informational, management and relational continuity impact patient and caregiver work. Conclusion: While all patient and caregiver work cannot be eliminated, their tasks may be reduced or better supported through improvements in continuity. By clarifying physical and cognitive work tasks and interpreting them through the lens of continuity of care, we were able to distil work into nine challenges that support translation of these themes into actionable interventions. Interventions that strengthen information transfer, clarify care plans, and provide targeted training and resources have the potential to lessen avoidable workload and improve transition experiences for patients and caregivers with complex care needs. Patient or Public Contribution: An advisory committee of patients with complex care needs and caregivers informed data collection (e.g., reviewed interview guide) and study output (vignette video). Clinical Trial Registration: ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 .

Learning Health Systems (LHS) are an increasingly common element of health policy reform efforts in a number of jurisdictions. There is little disagreement around the LHS vision, and early adopters provide some development guidance. Despite the attractiveness of the LHS vision, progress on adoption by systems remains slow. In this commentary, we consider one potential reason, namely politics, or the ways in which government bodies, interest groups, and political ideas shape structures and policies. LHS can change the ways that health systems work and interact with payors and populations and thereby create political challenges. The need for upfront new investment to build capacity for LHS activities, the creation of new partnerships or collaborations, increased transparency, and the direct engagement of populations can all create political risks and subsequent barriers. With a broad population health focus that extends across typical political cycles, politics may create an even greater barrier. We suggest that building strong engagement, clear and transparent accountabilities, communities of practice and other vehicles to promote data sharing and transparency, and careful attention to risk management may all help reduce political challenges. Some sets of policies—like value‐based care—can support these sorts of changes and accelerate the adoption of LHS.

Globally, health systems are increasingly striving to deliver evidence based care that improves patients’, caregivers’ and communities’ health outcomes. To deliver this care, more systems are engaging these groups to help inform healthcare service design and delivery. Their lived experiences—experiences accessing and/or supporting someone who accesses healthcare services—are now viewed by many systems as expertise and an important part of understanding and improving care quality. Patients’, caregivers’ and communities’ participation in health systems can range from healthcare organizational design to being members of research teams. Unfortunately, this involvement greatly varies and these groups are often sidelined to the start of research projects, with little to no role in later project stages. Additionally, some systems may forgo direct engagement, focusing solely on patient data collection and analysis. Given the benefits of active patient, caregiver and community participation in health systems on patient health outcomes, systems have begun identifying different approaches to studying and applying findings of patient, caregiver and community informed care initiatives in a rapid and consistent fashion. The learning health system (LHS) is one approach that can foster deeper and continuous engagement of these groups in health systems change. This approach embeds research into health systems, continuously learning from data and translating findings into healthcare practices in real time. Here, ongoing patient, caregiver and community involvement is considered vital for a well functioning LHS. Despite their importance, great variability exists as to what their involvement means in practice. This commentary examines the current state of patient, caregiver and community participation in the LHS. In particular, gaps in and need for resources to support their knowledge of the LHS are discussed. We conclude by recommending several factors health systems must consider in order to increase participation in their LHS. Systems must: (1) assess patients’, caregivers and community understanding of how their feedback are used in the LHS and how collected data are used to inform patient care; (2) review the level and extent of these groups’ participation in health system improvement activities; and (3) examine whether health systems have the workforce, capacity and infrastructure to nurture continuous and impactful engagement.

The vision of the learning health system (LHS), conceptualized 15 years ago, is for the rapid generation, use, and spread of high‐quality evidence that yields better health experiences, outcomes, efficiencies, and equity in everyday practice settings across communities. However, despite the emergence of many useful LHS frameworks and examples to guide adoption, large gaps remain in the speed and consistency with which evidence is generated and used across the range of settings from the bedside to the policy table. Gaps in progress are not surprising, however, given the tensions that predictably arise when key stakeholders—researchers, health systems, and funders—comingle in these efforts. This commentary examines eight core tensions that naturally arise and offers practical actions that stakeholders can take to address these tensions and speed LHS adoption. The urgency for attenuating these tensions and accelerating health system improvements has never been higher. Timeliness, rigor, and prioritization can be aligned across stakeholders, but only if all partners are intentional about the operational and cultural challenges that exist.

Racial-ethnic minority youth between the ages of 13 and 24 in the USA are disproportionately impacted by HIV. Low HIV knowledge and psychological antecedents such as low perception of risk and low sexual negotiation skills have all been associated with HIV risk behaviors; however, the role of ethnic identity on these factors is unclear in the literature. Ethnic identity, which is a critical part of identity development among racial-ethnic minority youth, has been found to be a protective factor in risk-taking behaviors. However, limited research is available on the role of ethnic identity in HIV prevention research among youth. For this study, data were collected as part of a larger HIV prevention education program using a sample of 564 students of color (Mean_age = 16.30, standard deviation [SD] = 1.26; 67.4% Hispanic, 29.5% Black) from an underserved northeastern US urban community. We examined whether ethnic identity moderated the relationship between psychological antecedents (e.g., perception of risk and sexual negotiation skills), gender, and viral hepatitis knowledge on HIV knowledge. Findings revealed that ethnic identity significantly moderated the relationship between psychological antecedent variables and HIV knowledge by strengthening these associations as ethnic identity increased. Female adolescents were also more likely to have higher levels of HIV knowledge than males. Findings provide support for cultural and gender-specific prevention programs for racial-ethnic minority youth that seek to reduce HIV risk behaviors by increasing ethnic identity, particularly in under-resourced communities.

Background: The perceived risk of coronavirus disease 2019 (COVID-19) infection for healthcare workers (HCWs) is high. Although testing has focused on symptomatic HCWs, asymptomatic testing is considered by some to be an important strategy to limit occupational spread. Evidence on the results of large asymptomatic testing strategies in healthcare is, however, limited. This study examines the uptake and positivity of COVID-19 testing in a voluntary asymptomatic testing campaign at a large Canadian hospital. Method: In addition to testing HCWs with symptoms, all asymptomatic staff were offered a COVID-19 test at Trillium Health Partners, a large Ontario hospital, from May 27 to June 15, 2020. Testing was offered in four waves, corresponding to the likelihood of exposure to COVID-19-positive patients. The mass asymptomatic testing campaign was offered when the hospital’s community test positivity rate had declined to 5%. Results: Since March 16, the hospital has tested 51.3% of its 10,143-person workforce at least once. In the asymptomatic testing campaign for HCWs between May 27 and June 15, 27% of clinical and non-clinical staff received testing. No large differences were found in the proportions of clinical HCWs tested by their exposure to COVID-19-positive patients. In this campaign, 0.2% of asymptomatic HCWs tested positive. However, these individuals either had mild symptoms at testing and did not self-identify or became symptomatic after testing. Conclusions: At this large hospital with declining community prevalence, a mass asymptomatic testing campaign of HCWs found they had a very low likelihood of testing positive for COVID-19.

Background: The perceived risk of coronavirus disease 2019 (COVID-19) infection for health care workers (HCWs) is high. Although testing has focused on symptomatic HCWs, asymptomatic testing is considered by some to be an important strategy to limit occupational spread. Evidence on the results of large asymptomatic testing strategies in health care is, however, limited. This study examines the uptake and positivity of COVID-19 testing in a voluntary asymptomatic testing campaign at a large Canadian hospital. Methods: In addition to testing HCWs with symptoms, all asymptomatic staff were offered a COVID-19 test at Trillium Health Partners, a large Ontario hospital, from May 27 to June 15, 2020. Testing was offered in four waves, corresponding to the likelihood of exposure to COVID-19–positive patients. The mass asymptomatic testing campaign was offered when the hospital’s community test positivity rate had declined to 5%. Results: Since March 16, the hospital has tested 51.3% of its 10,143-person workforce at least once. In the asymptomatic testing campaign for HCWs between May 27 and June 15, 27% of clinical and non-clinical staff received testing. No large differences were found in the proportions of clinical HCWs tested by their exposure to COVID-19–positive patients. In this campaign, 0.2% of asymptomatic HCWs tested positive. However, these individuals either had mild symptoms at testing and did not self-identify or became symptomatic after testing. Conclusions: At this large hospital with declining community prevalence, a mass asymptomatic testing campaign of HCWs found they had a very low likelihood of testing positive for COVID-19.

Background: Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. Objective: This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. Methods: The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. Results: This project is underway and expected to be complete by Spring 2024. Conclusions: Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. Trial Registration: ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 International Registered Report Identifier (IRRID): PRR1-10.2196/20220