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1 © 2015
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The Evolution of the Learning
Health System in Five Chapters
William A. Yasnoff, MD, PhD, FACMI
Managing Partner, NHII Advisors
Adjunct Professor, Division of
Health Sciences Informatics,
Johns Hopkins University
University of Michigan
February 10, 2015
© 2015
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2 © 2015
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LHS Evolution in Five Chapters
1. In the Beginning … [1970s]
2. Hints of a New Approach [1980s]
3. Foundations of the LHS [1990s]
●  EMRs
●  Registries
●  Decision Support
4. Informed Care: The Health
Information Infrastructure
(HII) Vision [2000s]
5. Building HII for LHS [2010s]
3 © 2015
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Chapter 1:
In the Beginning . . . [70s]
■  Patient care
●  Incomplete paper records
●  Knowledge in clinician’s head
■  Research
●  Clinical trials & case reports
●  Published literature
●  Dissemination dependent on
–  Clinician education (journals,
conferences)
–  Clinician memory
4 © 2015
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LHS Information Flow (old)
Patient Care
Individual Patient
Records (paper)
Clinician Memory
Research
Medical Literature
Case Reports
Problems
1. Very slow
2. Inconsistent
3. Uncertain
4. Huge missed
opportunities
5 © 2015
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LHS Report Card: Chapter 1
LHS Component 70s 80s 90s 00s 10s
Individual patient records D
Searchable records for other patients
Outcomes Data
Knowledge/Tools D
Publications C
Key Factors: Availability, Completeness, Speed
6 © 2015
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Chapter 2:
Hints of a New Approach [80s]
■  Medical College of Ohio Cardiology
Database
●  Inspired by Duke Databank for
Cardiovascular Disease
–  Started ~1965 for CCU patients
–  One of earliest medical databases
–  Today has comprehensive records
on 200K patients
■  AMA/Net
●  First comprehensive online
information network for physicians
7 © 2015
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MCO Cardiology Database*
■  Relational database with clinical
information about cardiology cases
■  Information entered manually
■  Outcomes data solicited by mail from
prior patients, added when received
■  Designed to answer the question,
“What happened to prior patients like
this one?”
■  Used in clinical conferences to
evaluate treatment options in complex
cases w/o clear literature guidance
*Yasnoff WA, Brewster PS, Demain-McGreevey K, Leighton RF, and Fraker Jr TD: A
Database System for Research, Teaching, and Clinical Decision Making in
Cardiology. In Proceedings of Computers in Cardiology, IEEE Press, pp. 77-82, 1984
8 © 2015
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AMA/Net – Faster Dissemination
■  Online information service for physicians
sponsored by AMA (late 1980s)*
■  Services
●  News
●  Literature (including clipping service)
●  Drug Interactions
●  Diagnostic Assistance – DxPlain
●  Therapeutic Assistance – Hypertension
Advisor
■  Dial-up, character based interface
■  40,000 subscribers at its peak
*Yasnoff WA: Electronic Information for Physicians: A New Dimension
in Solving Traditional Problems. Pennsylvania Medicine 92:48-50,
March, 1989.
9 © 2015
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LHS Report Card: Chapter 2
LHS Component 70s 80s 90s 00s 10s
Individual patient records D D+
Searchable records for other patients D
Outcomes Data
Knowledge/Tools D D+
Publications C C+
Key Factors: Availability, Completeness, Speed
10 © 2015
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Chapter 3:
Foundations of the LHS [90s]
■  IOM Reports
●  EHR reports (1991 & 97)
–  “The Computer-Based Patient Record”
–  “… an essential technology for
healthcare …”
–  Revised & updated in 1997
●  “To Err is Human” (1999)
–  44-98K unnecessary hospital deaths
–  Errors “systemic”
■  Immunization Registries
■  Decision Support
11 © 2015
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Immunization Registries
■  Developed in response to 1989-91 measles
outbreaks
■  RWJ Foundation funded early efforts ($25M)
followed by CDC ($250M)
■  Oregon “Immunization Alert” was first
successful statewide registry (1996)
●  Special bar coded forms collected data
●  Decision support*
●  Financially sustainable based on
reducing duplicate immunizations
■  Still operating successfully
*Miller PL, Frawley SJ, Sayward FG, Yasnoff WA, Duncan L, Fleming DW: Combining
Tabular, Rule-Based, and Procedural Knowledge in Computer-Based Guidelines for
Childhood Immunization. Computers and Biomed Res 30:211-31, 1997.
12 © 2015
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Decision Support
■  CDC Guidelines for Targeted TB
Testing and Rx of Latent TB
●  Encoded guidelines in computable
form (Arden syntax)
●  Designed for integration with EMRs
●  Can produce clinician reminders
■  CDC Prevention Guidelines*
●  360/1,069 (34%) of guidelines could
result in clinical reminders
●  Potential for integration into EMRs
*Garrett NY and Yasnoff WA: Disseminating Public Health Practice Guidelines in
Electronic Medical Record (EMR) Systems. J Public Health Management and
Practice 8(3):1-10, 2002
13 © 2015
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LHS Report Card: Chapter 3
LHS Component 70s 80s 90s 00s 10s
Individual patient records D D+ C
Searchable records for other patients D D
Outcomes Data D
Knowledge/Tools D D+ C
Publications C C+ B
Key Factors: Availability, Completeness, Speed
14 © 2015
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Chapter 4:
Informed Care: The Health Info
Infrastructure Vision [00s]
■  NCVHS Report (2001)
■  Development of DHHS Office of the
National Coordinator for Health IT
[ONC] (2002-4)
■  HII Progress Measures (2006-7)
■  LHS Vision from IOM (2007)
■  HITECH (2009)
15 © 2015
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NCVHS* “Information for Health”
■  NCVHS/Workgroup Chair: John Lumpkin, MD
●  Workgroup Member: Ted Shortliffe, MD, PhD
■  Coined the term “National Health Information
Infrastructure”
●  “A comprehensive knowledge-based system capable of
providing information to all who need it to make sound
decisions about health” to “support all facets of
individual health, health care, and public health”
●  “… implementation of the NHII will have a dramatic
impact on the effectiveness, efficiency, and overall
quality of health and health care in the U.S.”
■  Recommended $14 B budget over 10 years
■  Resulted in work leading to ONC
*National Committee on Vital and Health Statistics
16 © 2015
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Development of ONC 2002-4
■  9/02: WAY assigned to HHS
■  7/03: First-ever NHII conference developed
national consensus agenda*
●  600 attendees
●  HHS Secretary announces SNOMED
licensing for entire U.S. à standing
ovation
■  White House becomes interested in NHII
■  1/04: Electronic records in State of the Union
■  4/04: President signs Executive Order
creating ONC
*Yasnoff WA, Humphreys BL, Overhage JM, Detmer DE, Brennan PF, Morris RW,
Middleton B, Bates DW, Fanning JP: A Consensus Action Agenda for Achieving
the National Health Information Infrastructure. J Am Med Informatics Assoc 11(4):
332-338, 2004.
17 © 2015
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Measures for HII Progress*
■  Four Key Goals Measured
1. Completeness of Information
–  Fraction of people participating
–  Fraction of information available
2. Users of information
–  All physicians and all consumers
3. Uses of information: medical care, public
health, quality improvement, research, operations
4. Financial sustainability
■  Four Advanced Communities Scored Only
60-78 out of 100 à More Work Needed
*Labkoff SE and Yasnoff WA: A Framework for Systematic Evaluation of Health
Information Infrastructure Progress in Communities. J Biomed Informatics, 40(2):
100-105, 2007
18 © 2015
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IOM Vision of New LHS (2007)
■  Draw on Best Evidence to Provide
Care for Every Patient
■  Emphasize Prevention and Health
Promotion
■  Deliver Maximum Value
■  Add to Learning Throughout the
Delivery of Care
■  Lead to Improvements in the Nation’s
Health
Ensure innovation, quality,
safety and value in health care
19 © 2015
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HITECH - 2009
■  Accelerating EHR Adoption
●  Provider payments for EHR “Meaningful
Use”
●  $44K-64K over 5 years
■  Funding State Health Info Exchanges
●  $564 M (4 years)
●  Increasing state matching funds
●  Goal: “Facilitate and expand the secure electronic
movement and use of health information among
organizations according to nationally recognized standards”
●  More Useful Goal: “Facilitate the availability of
comprehensive electronic records for every patient”
“The utilization of an electronic health record for each
person in the U.S by 2014” – ONC Objective per HITECH
20 © 2015
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LHS Report Card: Chapter 4
LHS Component 70s 80s 90s 00s 10s
Individual patient records D D+ C C+
Searchable records for other patients D D D+
Outcomes Data D D
Knowledge/Tools D D+ C B
Publications C C+ B B
Key Factors: Availability, Completeness, Speed
21 © 2015
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Chapter 5:
Building HII for LHS [10s]
22 © 2015
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LHS Information Flow (goal)
Patient Care
Individual Patient
Records (paper)
Clinician Memory
Research
Medical Literature
Case Reports
Searchable Patient
Record Repository
Knowledge &
Tools
Decision Support
Abstraction
Analysis
Correlation
Genetics
Modeling
Pattern Recognition
Etc.
Outcomes
Data
(electronic)
Searchable Patient
Record Repository
23 © 2015
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HII Goals
■  Comprehensive electronic patient records
when & where needed
●  Individual (patient care)
●  Aggregate (research, population health)
■  Basic Requirements
●  All information must be electronic à all
providers must use EHRs
●  Mechanism to bring together scattered
information for each person (“Health
Information Exchange” or HIE)
24 © 2015
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HII Challenges
1. Privacy
●  Authorized access only
●  Authorized by whom?
2. Stakeholder Cooperation
●  All providers must submit records
3. All Digital Records
●  Paper records won’t do
4. Financial Sustainability
5. Security
●  Minimize hacking vulnerability
25 © 2015
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Case Study, Part 1
Diane, age 69
26 © 2015
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■  Wrong Path
●  Trying to replicate manual process of
contacting other providers directly for
records
Current HII Efforts Can’t Work
HIE
Index
Other
EHRs
Assembly
Clinician
EHR
Patient
Encounter
5
4
3
21
Diagram © Health Record Banking Alliance, 2013. Used by permission.
27 © 2015
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■  Complex and Expensive
●  All EHRs must be online 24/7 to
respond to queries
●  Real-time reconciliation of records
●  Requires unique patient identifier
–  Politically impractical
–  Privacy threat
●  Must have expensive 24/7 network
operations center to monitor all
contributing EHRs
Current Efforts Can’t Work (continued)
28 © 2015
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■  Increasing Errors with More Data Sources
Current Efforts Can’t Work (continued)
Source: Lapsia V, Lamb K, Yasnoff WA: Where should electronic records
for patients be stored? Int J Med Informatics 81:821-827, 2012.
29 © 2015
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■  Unable to Facilitate Robust Data
Searching
●  Distributed records à sequential
search
●  Sequential search is too slow to be
practical
Current Efforts Can’t Work (continued)
30 © 2015
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Solution:
Health Record Bank (HRB)
■  Secure community-based repository
of complete health records
■  Access to records completely
controlled by patients (or designee)
■  “Electronic safe deposit boxes”
■  Information about care deposited
once when created
●  Required by HIPAA
■  Allows EHR incentives to physicians
to make outpatient records electronic
■  Operation simple and inexpensive
31 © 2015
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http://www.healthbanking.org/video1.html
What is a Health Record Bank?
32 © 2015
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HRB Architecture
Patient
Records
Clinician
EHR
Patient
Encounter
HRB
1
3
2
Diagram © Health Record Banking Alliance, 2013. Used by permission.
33 © 2015
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HRB Rationale
■  Operationally simple
●  Records immediately available
●  Deposit new records when created
●  Enables value-added services
●  Enables research queries
■  Patient control
●  Trust & privacy
●  Stakeholder cooperation (HIPAA)
■  Low cost facilitates business model
●  Can fund EHR incentive options
–  Pay for deposits
–  Provide Internet-accessible EHRs
34 © 2015
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Focus Theme – Original Articles
Lessons Learned from a Health
Record Bank Start-up
W. A. Yasnoff1; E. H. Shortliffe2
1President, Health Record Banking Alliance (Arlington, VA); Managing Partner, National Health Information Infra-
structure (NHII) Advisors (Arlington, VA); Adjunct Professor, Division of Health Sciences Informatics, Johns Hopkins
University (Baltimore, MD);
2
Chair, Advisory Board, Health Record Banking Alliance (Arlington, VA); Professor and Senior Advisor, College of
Health Solutions, Arizona State University (Phoenix, AZ); Adjunct Professor, Columbia University (Biomedical In-
formatics) and Weill Cornell Medical College (Division of Quality and Medical Informatics, Department of Public
Health); Scholar in Residence, New York Academy of Medicine (New York, NY)
Keywords
Health record bank, health information infra-
structure, health information exchange, per-
sonal health records, electronic health rec-
ords, business model, clinical system imple-
mentation
sources of problems that were experienced,
and to identify lessons that need to be con-
sidered in future HRB ventures.
Methods: We describe staffing for the HRB
effort, the computational platform that was
developed, the approach to marketing, the
engagement of practicing physicians, and the
tori
mu
3) i
mu
gan
rec
sus
Methods Inf Med 2/2014
ation – physicians, hospitals, labora- tailored privacy policy. Stakeholder co-
35 © 2015
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How HRBs Create Value
Health Record Bank
including free/
subsidized EHRs for
physicians
More complete
electronic health
record informationEnables delivery of
optional services with
compelling value
Patients sign up for
HRB accounts
(recommended by
physicians)
Enables physicians to
provide better patient
care
$
36 © 2015
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HRB Business Model
■  Costs (with 1,000,000 subscribers)
●  Operations: $6/person/year
●  EHR incentives: $10/person/year
■  Revenue
●  Advertising: ~$3/person/year (option to
opt out for small fee)
●  Reminders & Alerts: >= $18/person/year
(30% penetration x $60/year)
–  “Peace of mind” alerts ($20/year)
–  Preventive care reminders ($20/year)
–  Medication reminders ($20/year)
●  Queries: >$3/person/year
■  No need to assume/capture any health
care cost savings (!!)
37 © 2015
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Pro Forma Example (Houston)
($1,000)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47
"Expenses ($K)"
"Revenue ($K)"
"Net ($K)"
Month
Initial Capital: $4.4 MM
Breakeven: 16 months
EBITDA Year 4: $41 MM+
38 © 2015
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Prevention & Population Health
■  Challenges
●  New activity
–  Providers do not do this now
–  Must hire staff & establish
procedures
●  Inefficient for each provider
–  More costly per capita to focus on
limited populations
●  Benefit externalities
–  Member “churn” limits ROI for
prevention
–  No incentive for long-term
prevention investments
39 © 2015
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Prevention & Population Health
■  Potential Solution: Collaborative
Community Prevention Organization
●  All providers pool resources
●  Community organization does
prevention & population health for all
■  Issues
●  Ongoing funding
●  Continuous provider cooperation
–  Initial capitalization
–  Annual operational funding
●  Incentives good but not compelling
●  Need comprehensive patient info
40 © 2015
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Point of View
A Proposal for Financially Sustainable
Population Health Organizations
William A. Yasnoff, MD, PhD,1
Edward H. Shortliffe, MD, PhD,2
and Stephen M. Shortell PhD, MPH, MBA3
Reconfiguring our health delivery sector to provide
safe and effective care, improve health, and simulta-
neously reduce costs requires both efficient, high-quality
medical services and community-wide population health and
prevention activities, supported by the immediate availability
of comprehensive electronic patient information.1
Given the
various health care stakeholders in our communities, who
often have divergent interests and incentives, how can we
establish and sustain organizations that can simultaneously
achieve all of these goals?
Shortell2,3
has proposed entities that might be called
population health organizations (PHOs) and that would
focus on addressing all of the determinants of health in a
organizations that serve as custodians of a comprehensive
integrated copy of each member’s personal, private health
information, including both medical records and personal
data that the patient may opt to add. They also could include
community-wide environmental health, housing, labor, and
related human services data. The patient explicitly controls
who may access which parts of the information in his or her
individual account.5,6
When patients seek care, they give
permission to their health care providers to access some or
all of their up-to-date health records available through the
HRB. At the patient’s request, when care is complete, the
new records from that visit or hospitalization are securely
deposited into the HRB and made available for future use.
POPULATION HEALTH MANAGEMENT
Volume 17, Number 5, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/pop.2014.0060
A Population Health Solution
41 © 2015
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Health and Prevention
Promotion Initiative (HAPPI)
■  Combine Community Prevention
Organization with Health Record Bank
■  Health Record Bank
●  Provides needed information
–  Ensures all-electronic records
●  Generates revenue (apps, ads, data)
●  Provides funds for itself and more
■  Excess Funds from HRB Pay for
Prevention and Population Health
■  Aligns All Stakeholder Interests
42 © 2015
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How does a HAPPI work?
PATIENT CONTROL
CENTRAL REPOSITORY
Stakeholder
Cooperation
ensures
Electronic Patient Data
provides
Benefits
1. Clinical: éQuality,êCosts
2. Reminders/Alerts
3. Research
produces
pay
for
enables
Prevention
(stakeholder need)
empowers
Privacy
protects
Financial
Incentives
ensure
Key
Design
Decisions
Initial Steps:
1. Free/subsidized EHRs for physicians
2. Physicians recruit patients for free HRB accounts
43 © 2015
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HRB Security Challenge
■  Centralized data best way to ensure security*
●  Distributed data less secure: multiple
transmission for each use
■  Inherent vulnerability of central database
●  Single point of access to all data
●  Potential loss of all data in one incident
■  Multiple security breaches à widespread
belief that nothing is secure
●  Perception is now reality
■  Challenge: Efficient search without
central database
*Turn R, Shapiro NZ, Juncosa ML. Privacy and Security in Centralized
vs. Decentralized Database Systems. Policy Sciences 1976;7:17-29.
44 © 2015
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Avoiding Total Data Loss
■  Each patient’s data
stored in central
location
●  Separate database
for each patient
●  Separate encryption
■  Pro: no single point of
access to all data
■  Con: Sequential
searching
Pt record 1*
Pt record 2
Pt record N
.
.
.
*each record stored and
encrypted separately
45 © 2015
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Searching Separate Records
Pt record 1*
Pt record 2
Pt record N
.
.
.
i ß 1
Retrieve record i
Decrypt record i
Search record i
i ß i+1
yesno
*each record stored and
encrypted separately
i > N? END
START
Requires N iterations
46 © 2015
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Searching: 2 Processors
Pt record 1*
Pt record 2
Pt record N
.
.
.
i ß 1
Retrieve record i
Decrypt record i
Search record i
i ß i+2
yesno
*each record stored and
encrypted separately
i>(N-1)? END
START
Requires N/2 iterations
Retrieve record i+1
Decrypt record i+1
Search record i+1
47 © 2015
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Searching: K Processors
i ß 1
i ß i+K
no
i>(N-K)?
yes
END
START
Requires N/K iterations
Retrieve rec i Retrieve rec i+1 Retrieve rec i+K-1
Search rec i Search rec i+1 Search rec i+K-1
Decrypt rec i Decrypt rec i+1 Decrypt rec i+K-1
. . .
. . .
. . .
In cloud environment,
K can be 1,000 or even
10,000 à fast searching
48 © 2015
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Personal Health Grid™ (PHG)*
■  Each patient’s record stored in
separate database with separate
encryption
■  Efficient massively parallel searching
using virtual processors in cloud and/
or network (which may include mobile
phones)
■  No access point for all patients’ data –
even for operator of service
●  Eliminates “database in the sky”
security vulnerability
*patent pending (January, 2015)
49 © 2015
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HRB + HAPPI + PHG = HII Solution
1. Privacy – patient control
2. Stakeholder cooperation – patient
control and ongoing incentives
3. All digital information – ongoing
incentives
4. Financial sustainability
●  Apps for patients
●  Apps for other stakeholders
5. Security – Personal Health Grid™
avoids potential for loss of all data
Anticipate rapid progress in HRB development
50 © 2015
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Case Study, Part 2
Diane, age 69
51 © 2015
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SUMMARY
■  LHS Used to be Publications and
Slow Manual Dissemination
■  New LHS Vision: Every Patient
Benefits from and Contributes to an
Accessible Experience Base
■  Current LHS Vision Requires Health
Information Infrastructure (HII)
■  HII Requires HRBs, HAPPI, & PHG
●  Solves five key HII challenges
■  Anticipated Results
●  A Real Learning Health System
●  Successful Pursuit of Triple Aim
52 © 2015
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ADVISORS
LHS Report Card: Chapter 5
LHS Component 70s 80s 90s 00s 10s
Individual patient records D D+ C C+ ?
Searchable records for other patients D D D+ ?
Outcomes Data D D ?
Knowledge/Tools D D+ C B ?
Publications C C+ B B ?
Key Factors: Availability, Completeness, Speed
53 © 2015
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Questions?
William A. Yasnoff, MD, PhD, FACMI
william.yasnoff@nhiiadvisors.com
703/527-5678
54 © 2015
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Commercial Interest
None
No unlabeled/unapproved uses of drugs or products
William A. Yasnoff, MD, PhD
55 © 2015
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LEARNING OBJECTIVES
1.  Explain the differences between how learning in the
health system occurs now vs. what is envisioned in
the Learning Health System
2.  Name the four basic functions of the Learning Health
System
3.  Explain why an effective health information
infrastructure is an essential component of the
Learning Health System
4.  Name four key challenges to the development of
health information infrastructure and how a health
record bank architecture addresses each one

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The Learning Health System in 5 Chapters - Guest speaker, William A. Yasnoff

  • 1. 1 © 2015 N H I I ADVISORS The Evolution of the Learning Health System in Five Chapters William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Adjunct Professor, Division of Health Sciences Informatics, Johns Hopkins University University of Michigan February 10, 2015 © 2015 N H I I ADVISORS
  • 2. 2 © 2015 N H I I ADVISORS LHS Evolution in Five Chapters 1. In the Beginning … [1970s] 2. Hints of a New Approach [1980s] 3. Foundations of the LHS [1990s] ●  EMRs ●  Registries ●  Decision Support 4. Informed Care: The Health Information Infrastructure (HII) Vision [2000s] 5. Building HII for LHS [2010s]
  • 3. 3 © 2015 N H I I ADVISORS Chapter 1: In the Beginning . . . [70s] ■  Patient care ●  Incomplete paper records ●  Knowledge in clinician’s head ■  Research ●  Clinical trials & case reports ●  Published literature ●  Dissemination dependent on –  Clinician education (journals, conferences) –  Clinician memory
  • 4. 4 © 2015 N H I I ADVISORS LHS Information Flow (old) Patient Care Individual Patient Records (paper) Clinician Memory Research Medical Literature Case Reports Problems 1. Very slow 2. Inconsistent 3. Uncertain 4. Huge missed opportunities
  • 5. 5 © 2015 N H I I ADVISORS LHS Report Card: Chapter 1 LHS Component 70s 80s 90s 00s 10s Individual patient records D Searchable records for other patients Outcomes Data Knowledge/Tools D Publications C Key Factors: Availability, Completeness, Speed
  • 6. 6 © 2015 N H I I ADVISORS Chapter 2: Hints of a New Approach [80s] ■  Medical College of Ohio Cardiology Database ●  Inspired by Duke Databank for Cardiovascular Disease –  Started ~1965 for CCU patients –  One of earliest medical databases –  Today has comprehensive records on 200K patients ■  AMA/Net ●  First comprehensive online information network for physicians
  • 7. 7 © 2015 N H I I ADVISORS MCO Cardiology Database* ■  Relational database with clinical information about cardiology cases ■  Information entered manually ■  Outcomes data solicited by mail from prior patients, added when received ■  Designed to answer the question, “What happened to prior patients like this one?” ■  Used in clinical conferences to evaluate treatment options in complex cases w/o clear literature guidance *Yasnoff WA, Brewster PS, Demain-McGreevey K, Leighton RF, and Fraker Jr TD: A Database System for Research, Teaching, and Clinical Decision Making in Cardiology. In Proceedings of Computers in Cardiology, IEEE Press, pp. 77-82, 1984
  • 8. 8 © 2015 N H I I ADVISORS AMA/Net – Faster Dissemination ■  Online information service for physicians sponsored by AMA (late 1980s)* ■  Services ●  News ●  Literature (including clipping service) ●  Drug Interactions ●  Diagnostic Assistance – DxPlain ●  Therapeutic Assistance – Hypertension Advisor ■  Dial-up, character based interface ■  40,000 subscribers at its peak *Yasnoff WA: Electronic Information for Physicians: A New Dimension in Solving Traditional Problems. Pennsylvania Medicine 92:48-50, March, 1989.
  • 9. 9 © 2015 N H I I ADVISORS LHS Report Card: Chapter 2 LHS Component 70s 80s 90s 00s 10s Individual patient records D D+ Searchable records for other patients D Outcomes Data Knowledge/Tools D D+ Publications C C+ Key Factors: Availability, Completeness, Speed
  • 10. 10 © 2015 N H I I ADVISORS Chapter 3: Foundations of the LHS [90s] ■  IOM Reports ●  EHR reports (1991 & 97) –  “The Computer-Based Patient Record” –  “… an essential technology for healthcare …” –  Revised & updated in 1997 ●  “To Err is Human” (1999) –  44-98K unnecessary hospital deaths –  Errors “systemic” ■  Immunization Registries ■  Decision Support
  • 11. 11 © 2015 N H I I ADVISORS Immunization Registries ■  Developed in response to 1989-91 measles outbreaks ■  RWJ Foundation funded early efforts ($25M) followed by CDC ($250M) ■  Oregon “Immunization Alert” was first successful statewide registry (1996) ●  Special bar coded forms collected data ●  Decision support* ●  Financially sustainable based on reducing duplicate immunizations ■  Still operating successfully *Miller PL, Frawley SJ, Sayward FG, Yasnoff WA, Duncan L, Fleming DW: Combining Tabular, Rule-Based, and Procedural Knowledge in Computer-Based Guidelines for Childhood Immunization. Computers and Biomed Res 30:211-31, 1997.
  • 12. 12 © 2015 N H I I ADVISORS Decision Support ■  CDC Guidelines for Targeted TB Testing and Rx of Latent TB ●  Encoded guidelines in computable form (Arden syntax) ●  Designed for integration with EMRs ●  Can produce clinician reminders ■  CDC Prevention Guidelines* ●  360/1,069 (34%) of guidelines could result in clinical reminders ●  Potential for integration into EMRs *Garrett NY and Yasnoff WA: Disseminating Public Health Practice Guidelines in Electronic Medical Record (EMR) Systems. J Public Health Management and Practice 8(3):1-10, 2002
  • 13. 13 © 2015 N H I I ADVISORS LHS Report Card: Chapter 3 LHS Component 70s 80s 90s 00s 10s Individual patient records D D+ C Searchable records for other patients D D Outcomes Data D Knowledge/Tools D D+ C Publications C C+ B Key Factors: Availability, Completeness, Speed
  • 14. 14 © 2015 N H I I ADVISORS Chapter 4: Informed Care: The Health Info Infrastructure Vision [00s] ■  NCVHS Report (2001) ■  Development of DHHS Office of the National Coordinator for Health IT [ONC] (2002-4) ■  HII Progress Measures (2006-7) ■  LHS Vision from IOM (2007) ■  HITECH (2009)
  • 15. 15 © 2015 N H I I ADVISORS NCVHS* “Information for Health” ■  NCVHS/Workgroup Chair: John Lumpkin, MD ●  Workgroup Member: Ted Shortliffe, MD, PhD ■  Coined the term “National Health Information Infrastructure” ●  “A comprehensive knowledge-based system capable of providing information to all who need it to make sound decisions about health” to “support all facets of individual health, health care, and public health” ●  “… implementation of the NHII will have a dramatic impact on the effectiveness, efficiency, and overall quality of health and health care in the U.S.” ■  Recommended $14 B budget over 10 years ■  Resulted in work leading to ONC *National Committee on Vital and Health Statistics
  • 16. 16 © 2015 N H I I ADVISORS Development of ONC 2002-4 ■  9/02: WAY assigned to HHS ■  7/03: First-ever NHII conference developed national consensus agenda* ●  600 attendees ●  HHS Secretary announces SNOMED licensing for entire U.S. à standing ovation ■  White House becomes interested in NHII ■  1/04: Electronic records in State of the Union ■  4/04: President signs Executive Order creating ONC *Yasnoff WA, Humphreys BL, Overhage JM, Detmer DE, Brennan PF, Morris RW, Middleton B, Bates DW, Fanning JP: A Consensus Action Agenda for Achieving the National Health Information Infrastructure. J Am Med Informatics Assoc 11(4): 332-338, 2004.
  • 17. 17 © 2015 N H I I ADVISORS Measures for HII Progress* ■  Four Key Goals Measured 1. Completeness of Information –  Fraction of people participating –  Fraction of information available 2. Users of information –  All physicians and all consumers 3. Uses of information: medical care, public health, quality improvement, research, operations 4. Financial sustainability ■  Four Advanced Communities Scored Only 60-78 out of 100 à More Work Needed *Labkoff SE and Yasnoff WA: A Framework for Systematic Evaluation of Health Information Infrastructure Progress in Communities. J Biomed Informatics, 40(2): 100-105, 2007
  • 18. 18 © 2015 N H I I ADVISORS IOM Vision of New LHS (2007) ■  Draw on Best Evidence to Provide Care for Every Patient ■  Emphasize Prevention and Health Promotion ■  Deliver Maximum Value ■  Add to Learning Throughout the Delivery of Care ■  Lead to Improvements in the Nation’s Health Ensure innovation, quality, safety and value in health care
  • 19. 19 © 2015 N H I I ADVISORS HITECH - 2009 ■  Accelerating EHR Adoption ●  Provider payments for EHR “Meaningful Use” ●  $44K-64K over 5 years ■  Funding State Health Info Exchanges ●  $564 M (4 years) ●  Increasing state matching funds ●  Goal: “Facilitate and expand the secure electronic movement and use of health information among organizations according to nationally recognized standards” ●  More Useful Goal: “Facilitate the availability of comprehensive electronic records for every patient” “The utilization of an electronic health record for each person in the U.S by 2014” – ONC Objective per HITECH
  • 20. 20 © 2015 N H I I ADVISORS LHS Report Card: Chapter 4 LHS Component 70s 80s 90s 00s 10s Individual patient records D D+ C C+ Searchable records for other patients D D D+ Outcomes Data D D Knowledge/Tools D D+ C B Publications C C+ B B Key Factors: Availability, Completeness, Speed
  • 21. 21 © 2015 N H I I ADVISORS Chapter 5: Building HII for LHS [10s]
  • 22. 22 © 2015 N H I I ADVISORS LHS Information Flow (goal) Patient Care Individual Patient Records (paper) Clinician Memory Research Medical Literature Case Reports Searchable Patient Record Repository Knowledge & Tools Decision Support Abstraction Analysis Correlation Genetics Modeling Pattern Recognition Etc. Outcomes Data (electronic) Searchable Patient Record Repository
  • 23. 23 © 2015 N H I I ADVISORS HII Goals ■  Comprehensive electronic patient records when & where needed ●  Individual (patient care) ●  Aggregate (research, population health) ■  Basic Requirements ●  All information must be electronic à all providers must use EHRs ●  Mechanism to bring together scattered information for each person (“Health Information Exchange” or HIE)
  • 24. 24 © 2015 N H I I ADVISORS HII Challenges 1. Privacy ●  Authorized access only ●  Authorized by whom? 2. Stakeholder Cooperation ●  All providers must submit records 3. All Digital Records ●  Paper records won’t do 4. Financial Sustainability 5. Security ●  Minimize hacking vulnerability
  • 25. 25 © 2015 N H I I ADVISORS Case Study, Part 1 Diane, age 69
  • 26. 26 © 2015 N H I I ADVISORS ■  Wrong Path ●  Trying to replicate manual process of contacting other providers directly for records Current HII Efforts Can’t Work HIE Index Other EHRs Assembly Clinician EHR Patient Encounter 5 4 3 21 Diagram © Health Record Banking Alliance, 2013. Used by permission.
  • 27. 27 © 2015 N H I I ADVISORS ■  Complex and Expensive ●  All EHRs must be online 24/7 to respond to queries ●  Real-time reconciliation of records ●  Requires unique patient identifier –  Politically impractical –  Privacy threat ●  Must have expensive 24/7 network operations center to monitor all contributing EHRs Current Efforts Can’t Work (continued)
  • 28. 28 © 2015 N H I I ADVISORS ■  Increasing Errors with More Data Sources Current Efforts Can’t Work (continued) Source: Lapsia V, Lamb K, Yasnoff WA: Where should electronic records for patients be stored? Int J Med Informatics 81:821-827, 2012.
  • 29. 29 © 2015 N H I I ADVISORS ■  Unable to Facilitate Robust Data Searching ●  Distributed records à sequential search ●  Sequential search is too slow to be practical Current Efforts Can’t Work (continued)
  • 30. 30 © 2015 N H I I ADVISORS Solution: Health Record Bank (HRB) ■  Secure community-based repository of complete health records ■  Access to records completely controlled by patients (or designee) ■  “Electronic safe deposit boxes” ■  Information about care deposited once when created ●  Required by HIPAA ■  Allows EHR incentives to physicians to make outpatient records electronic ■  Operation simple and inexpensive
  • 31. 31 © 2015 N H I I ADVISORS http://www.healthbanking.org/video1.html What is a Health Record Bank?
  • 32. 32 © 2015 N H I I ADVISORS HRB Architecture Patient Records Clinician EHR Patient Encounter HRB 1 3 2 Diagram © Health Record Banking Alliance, 2013. Used by permission.
  • 33. 33 © 2015 N H I I ADVISORS HRB Rationale ■  Operationally simple ●  Records immediately available ●  Deposit new records when created ●  Enables value-added services ●  Enables research queries ■  Patient control ●  Trust & privacy ●  Stakeholder cooperation (HIPAA) ■  Low cost facilitates business model ●  Can fund EHR incentive options –  Pay for deposits –  Provide Internet-accessible EHRs
  • 34. 34 © 2015 N H I I ADVISORS Focus Theme – Original Articles Lessons Learned from a Health Record Bank Start-up W. A. Yasnoff1; E. H. Shortliffe2 1President, Health Record Banking Alliance (Arlington, VA); Managing Partner, National Health Information Infra- structure (NHII) Advisors (Arlington, VA); Adjunct Professor, Division of Health Sciences Informatics, Johns Hopkins University (Baltimore, MD); 2 Chair, Advisory Board, Health Record Banking Alliance (Arlington, VA); Professor and Senior Advisor, College of Health Solutions, Arizona State University (Phoenix, AZ); Adjunct Professor, Columbia University (Biomedical In- formatics) and Weill Cornell Medical College (Division of Quality and Medical Informatics, Department of Public Health); Scholar in Residence, New York Academy of Medicine (New York, NY) Keywords Health record bank, health information infra- structure, health information exchange, per- sonal health records, electronic health rec- ords, business model, clinical system imple- mentation sources of problems that were experienced, and to identify lessons that need to be con- sidered in future HRB ventures. Methods: We describe staffing for the HRB effort, the computational platform that was developed, the approach to marketing, the engagement of practicing physicians, and the tori mu 3) i mu gan rec sus Methods Inf Med 2/2014 ation – physicians, hospitals, labora- tailored privacy policy. Stakeholder co-
  • 35. 35 © 2015 N H I I ADVISORS How HRBs Create Value Health Record Bank including free/ subsidized EHRs for physicians More complete electronic health record informationEnables delivery of optional services with compelling value Patients sign up for HRB accounts (recommended by physicians) Enables physicians to provide better patient care $
  • 36. 36 © 2015 N H I I ADVISORS HRB Business Model ■  Costs (with 1,000,000 subscribers) ●  Operations: $6/person/year ●  EHR incentives: $10/person/year ■  Revenue ●  Advertising: ~$3/person/year (option to opt out for small fee) ●  Reminders & Alerts: >= $18/person/year (30% penetration x $60/year) –  “Peace of mind” alerts ($20/year) –  Preventive care reminders ($20/year) –  Medication reminders ($20/year) ●  Queries: >$3/person/year ■  No need to assume/capture any health care cost savings (!!)
  • 37. 37 © 2015 N H I I ADVISORS Pro Forma Example (Houston) ($1,000) $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 "Expenses ($K)" "Revenue ($K)" "Net ($K)" Month Initial Capital: $4.4 MM Breakeven: 16 months EBITDA Year 4: $41 MM+
  • 38. 38 © 2015 N H I I ADVISORS Prevention & Population Health ■  Challenges ●  New activity –  Providers do not do this now –  Must hire staff & establish procedures ●  Inefficient for each provider –  More costly per capita to focus on limited populations ●  Benefit externalities –  Member “churn” limits ROI for prevention –  No incentive for long-term prevention investments
  • 39. 39 © 2015 N H I I ADVISORS Prevention & Population Health ■  Potential Solution: Collaborative Community Prevention Organization ●  All providers pool resources ●  Community organization does prevention & population health for all ■  Issues ●  Ongoing funding ●  Continuous provider cooperation –  Initial capitalization –  Annual operational funding ●  Incentives good but not compelling ●  Need comprehensive patient info
  • 40. 40 © 2015 N H I I ADVISORS Point of View A Proposal for Financially Sustainable Population Health Organizations William A. Yasnoff, MD, PhD,1 Edward H. Shortliffe, MD, PhD,2 and Stephen M. Shortell PhD, MPH, MBA3 Reconfiguring our health delivery sector to provide safe and effective care, improve health, and simulta- neously reduce costs requires both efficient, high-quality medical services and community-wide population health and prevention activities, supported by the immediate availability of comprehensive electronic patient information.1 Given the various health care stakeholders in our communities, who often have divergent interests and incentives, how can we establish and sustain organizations that can simultaneously achieve all of these goals? Shortell2,3 has proposed entities that might be called population health organizations (PHOs) and that would focus on addressing all of the determinants of health in a organizations that serve as custodians of a comprehensive integrated copy of each member’s personal, private health information, including both medical records and personal data that the patient may opt to add. They also could include community-wide environmental health, housing, labor, and related human services data. The patient explicitly controls who may access which parts of the information in his or her individual account.5,6 When patients seek care, they give permission to their health care providers to access some or all of their up-to-date health records available through the HRB. At the patient’s request, when care is complete, the new records from that visit or hospitalization are securely deposited into the HRB and made available for future use. POPULATION HEALTH MANAGEMENT Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2014.0060 A Population Health Solution
  • 41. 41 © 2015 N H I I ADVISORS Health and Prevention Promotion Initiative (HAPPI) ■  Combine Community Prevention Organization with Health Record Bank ■  Health Record Bank ●  Provides needed information –  Ensures all-electronic records ●  Generates revenue (apps, ads, data) ●  Provides funds for itself and more ■  Excess Funds from HRB Pay for Prevention and Population Health ■  Aligns All Stakeholder Interests
  • 42. 42 © 2015 N H I I ADVISORS How does a HAPPI work? PATIENT CONTROL CENTRAL REPOSITORY Stakeholder Cooperation ensures Electronic Patient Data provides Benefits 1. Clinical: éQuality,êCosts 2. Reminders/Alerts 3. Research produces pay for enables Prevention (stakeholder need) empowers Privacy protects Financial Incentives ensure Key Design Decisions Initial Steps: 1. Free/subsidized EHRs for physicians 2. Physicians recruit patients for free HRB accounts
  • 43. 43 © 2015 N H I I ADVISORS HRB Security Challenge ■  Centralized data best way to ensure security* ●  Distributed data less secure: multiple transmission for each use ■  Inherent vulnerability of central database ●  Single point of access to all data ●  Potential loss of all data in one incident ■  Multiple security breaches à widespread belief that nothing is secure ●  Perception is now reality ■  Challenge: Efficient search without central database *Turn R, Shapiro NZ, Juncosa ML. Privacy and Security in Centralized vs. Decentralized Database Systems. Policy Sciences 1976;7:17-29.
  • 44. 44 © 2015 N H I I ADVISORS Avoiding Total Data Loss ■  Each patient’s data stored in central location ●  Separate database for each patient ●  Separate encryption ■  Pro: no single point of access to all data ■  Con: Sequential searching Pt record 1* Pt record 2 Pt record N . . . *each record stored and encrypted separately
  • 45. 45 © 2015 N H I I ADVISORS Searching Separate Records Pt record 1* Pt record 2 Pt record N . . . i ß 1 Retrieve record i Decrypt record i Search record i i ß i+1 yesno *each record stored and encrypted separately i > N? END START Requires N iterations
  • 46. 46 © 2015 N H I I ADVISORS Searching: 2 Processors Pt record 1* Pt record 2 Pt record N . . . i ß 1 Retrieve record i Decrypt record i Search record i i ß i+2 yesno *each record stored and encrypted separately i>(N-1)? END START Requires N/2 iterations Retrieve record i+1 Decrypt record i+1 Search record i+1
  • 47. 47 © 2015 N H I I ADVISORS Searching: K Processors i ß 1 i ß i+K no i>(N-K)? yes END START Requires N/K iterations Retrieve rec i Retrieve rec i+1 Retrieve rec i+K-1 Search rec i Search rec i+1 Search rec i+K-1 Decrypt rec i Decrypt rec i+1 Decrypt rec i+K-1 . . . . . . . . . In cloud environment, K can be 1,000 or even 10,000 à fast searching
  • 48. 48 © 2015 N H I I ADVISORS Personal Health Grid™ (PHG)* ■  Each patient’s record stored in separate database with separate encryption ■  Efficient massively parallel searching using virtual processors in cloud and/ or network (which may include mobile phones) ■  No access point for all patients’ data – even for operator of service ●  Eliminates “database in the sky” security vulnerability *patent pending (January, 2015)
  • 49. 49 © 2015 N H I I ADVISORS HRB + HAPPI + PHG = HII Solution 1. Privacy – patient control 2. Stakeholder cooperation – patient control and ongoing incentives 3. All digital information – ongoing incentives 4. Financial sustainability ●  Apps for patients ●  Apps for other stakeholders 5. Security – Personal Health Grid™ avoids potential for loss of all data Anticipate rapid progress in HRB development
  • 50. 50 © 2015 N H I I ADVISORS Case Study, Part 2 Diane, age 69
  • 51. 51 © 2015 N H I I ADVISORS SUMMARY ■  LHS Used to be Publications and Slow Manual Dissemination ■  New LHS Vision: Every Patient Benefits from and Contributes to an Accessible Experience Base ■  Current LHS Vision Requires Health Information Infrastructure (HII) ■  HII Requires HRBs, HAPPI, & PHG ●  Solves five key HII challenges ■  Anticipated Results ●  A Real Learning Health System ●  Successful Pursuit of Triple Aim
  • 52. 52 © 2015 N H I I ADVISORS LHS Report Card: Chapter 5 LHS Component 70s 80s 90s 00s 10s Individual patient records D D+ C C+ ? Searchable records for other patients D D D+ ? Outcomes Data D D ? Knowledge/Tools D D+ C B ? Publications C C+ B B ? Key Factors: Availability, Completeness, Speed
  • 53. 53 © 2015 N H I I ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678
  • 54. 54 © 2015 N H I I ADVISORS Commercial Interest None No unlabeled/unapproved uses of drugs or products William A. Yasnoff, MD, PhD
  • 55. 55 © 2015 N H I I ADVISORS LEARNING OBJECTIVES 1.  Explain the differences between how learning in the health system occurs now vs. what is envisioned in the Learning Health System 2.  Name the four basic functions of the Learning Health System 3.  Explain why an effective health information infrastructure is an essential component of the Learning Health System 4.  Name four key challenges to the development of health information infrastructure and how a health record bank architecture addresses each one