1. Steven M. Asch MD MPH National Academy of Medicine May 22, 2019
Publishing Implementation Science and QI from Learning Health Care Systems
Steven M. Asch MD MPH
National Academy of Medicine
May 22, 2019
Thanks. For my 7 minutes I want to talk about how to deal with a particularly challenging issue for publishing data from learning health care systems – what to do with the very applied end.

2. Learning Healthcare Systems Lean Right on Translation Spectrum
Basic
Science
Clinical
Trials
Clinical
Epidemiology
Health
Services
Research
Implemen-tation
Science
Quality
Improvement
As we have discussed today, data from delivery systems can inform the full translational spectrum of inquiry, from basic science and clinical trials to clin epi, to traditional health services research investigating access and quality and cost, to how to disseminate best practices in implementation science and quality improvement. But what do learning health care systems want to learn about most. My experience is that what they lean right on this translation spectrum. What they really want to learn about is what they do – implementation and quality improvement.
Learning Healthcare Systems Lean Right
on Translation Spectrum

3. Generalizablity > Internal Validity
Basic
Science
Clinical
Trials
Clinical
Epidemiology
Health
Services
Research
Implemen-tation
Science
Quality
Improvement
Generalizablity > Internal Validity

4. Clinical trials actively try to eliminate and control for context; implementation science and quality improvement instead take context, especially organizational context, as an important object of study. Translation: LHS want to learn about themselves.
May CR: Implementation Science :141

5. Analytic capacity no longer (even mostly) the domain of researchers
These are the approaches behind “market basket” analysis.
Why is it that your supermarket will give you free discounts on your groceries if you sign up for a club card. It’s because they can now use that to track what you’re buying now and over time. The classic allegory here is one supermarket found that people buy Beer and Diapers together much more than you would expect by random chance, which gave the market manager’s ideas for strategically placing all of their expensive alcohol next to the diaper section to increase impulse buys.
This article from the NY times had a particularly colorful story of
Target predicting high school daughter’s pregnancy before father knew
Unscented lotion, cotton balls, hand sanitizers, large purse = diaper bag
Onion: Amazon knows wife’s preferences better than husband

6. Doctors Like You Ordered Things Like These on Patients Like Yours…
These are the approaches behind “market basket” analysis.
Why is it that your supermarket will give you free discounts on your groceries if you sign up for a club card. It’s because they can now use that to track what you’re buying now and over time. The classic allegory here is one supermarket found that people buy Beer and Diapers together much more than you would expect by random chance, which gave the market manager’s ideas for strategically placing all of their expensive alcohol next to the diaper section to increase impulse buys.
This article from the NY times had a particularly colorful story of
Target predicting high school daughter’s pregnancy before father knew
Unscented lotion, cotton balls, hand sanitizers, large purse = diaper bag
Onion: Amazon knows wife’s preferences better than husband

7. A Data Consult Service
Given a specific case, provides a report summarizing similar patients in Stanford’s clinical data warehouse, the common treatment choices made, and the observed outcomes. greenbutton.stanford.edu What do we do when LHS want to publish this work?
Green button = the vision of using data from similar patients at the bedside.
Consult Service = our embodiment of that vision at Stanford.
Prev, such efforts:
1972 – Feinstein et al,
1974 – Rosati et al,

8. Reporting standards for implementation science/QI SQUIRE (Standards for Quality Improvement Reporting Excellence) StaRI (Standards for Reporting Implementation Studies) QI-MCS (Quality Improvement Minimum Quality Criteria Set)
Like CONSORT for clinical trials or STROBE for clinical epi, both included in the background materials, there are reporting requirements. All explicitly take context as a subject matter for study.
Ogrinc C: BMJ Quality & Safety 2016;25:
Pinnock H: BM J2017;356:i6795
Hempel S: BMJ Qual Saf 2015;24:796–804

9. Discussion Points
Much of what learning health care systems study is themselves
Puts much of their intellectual product in the domains of implementation science and quality improvement
Context is king of that domain, but dissemination still important
Need rigorous reporting standards that guide field but take context into account