Participants and other stakeholders in today’s U.S. health care system are striving for the generation of new knowledge to guide care while at the same time they are also managing growing clinical and organizational complexity, directing considerable attention to curbing health care costs, and reducing inefficiencies. An important early milestone toward achieving these goals was the establishment of the Center for Medicare & Medicaid Innovation (CMMI) following the passage of the Patient Protection and Affordable Care Act (ACA) of 2010 to promote innovations in care delivery that fulfill the Triple Aim of improving health and health care at lower cost. In January 2015 the U.S. Department of Health and Human Services established the Health Care Payment Learning & Action Network (HCP-LAN, or LAN) to work in concert with partners in the private, public, and nonprofit sectors to transform the nation’s health system to emphasize value over volume by supporting and advancing the adoption of value-based payment and alternative payment models. Passage in 2015 of the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act (MACRA) with strong bipartisan, bicameral support in Congress and from the White House set America’s health care system on a path to reform that emphasizes value over volume in federal payment programs. On November 2, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017 (the Rule) (CMS, 2016). The Rule implements provisions in MACRA intended to promote quality, improvement activities, accessing care information, and attention to cost. These initiatives set the stage for broad engagement of patients and providers in the learning health system.
Beyond payment reform emphasizing health care value, opportunities to address the challenges facing modern health care can be found within a continuously learning health system, a bidirectional approach to learning in which the care delivery process creates new knowledge and care is adapted in response to knowledge generated. The Institute of Medicine report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America laid out a vision for a continuously learning health system, stating that: “The committee believes that achieving a learning health care system—one in which science and informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care—is both necessary and possible for the nation.”
However, we assert that realization of the full potential of the continuously learning health system requires more active engagement of front-line clinicians (defined here as providers involved in day-to-day patient care interactions). Instead of the compartmentalized approach to knowledge generation, in which research that informs the delivery of care is separate from the care experience, we contend that future knowledge generation will be best accomplished with fully engaged clinicians, patients, and health care data.
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