Quarterly Updates and News of the LHS

The purpose of this quarterly update is to provide all stakeholders with an update on the progress of the PM&R LHS project. 

Recap: What is the overall goal of the PMR LHS Project?

PM&R Learning Health System (LHS) Mission Statement: To learn from every patient by aligning clinical care, science, informatics, and culture, enabling continuous improvement and innovation in the practice of medical rehabilitation.

Recap: What are the attributes of a Learning Health System?

According to the Agency for Healthcare Research and Quality (AHRQ), the following are key attributes of Learning Health Systems:

• Having leaders who are committed to a culture of continuous learning and improvement
• Systematically gathering and applying evidence in real-time to guide care
• Employing IT methods to share new evidence with clinicians to improve decision-making
• Promoting the inclusion of patients as vital members of the learning team
• Capturing and analyzing data and care experiences to improve care
• Continually assessing outcomes, refining processes and training to create a feedback cycle for learning and improvement

What progress was made over the past quarter?

Listed below are several of the major accomplishments from the past extended quarter (August 2020-January 2021):

• Eight LHS Teams were launched in 2020. Over the last quarter, the LHS teams focused on two main areas of advancement: (1) selecting clinically useful standardized measures and (2) streamlining documentation practices to produce extractable data. The ultimate goal of this effort is to produce high quality data from every patient and every encounter that is used to produce new knowledge that informs practice.
• Claire Kalpakjian, PhD, MS, Faculty Lead for the PM&R Learning Health System, will present a plenary at the September 2021 American Congress of Rehabilitation Medicine Conference, entitled “The Learning Health System Model: The Practical and Moral Imperative for Embracing an Organizing Framework for Rehabilitation”.
• Victor Rentes, Graduate Student Research Assistant, and PhD Candidate at the Department of Learning Health Sciences, joined the PM&R LHS team to develop the first LHS Maturity Model. The new model draws on PM&R’s hands on experience developing a LHS and draws on established maturity models in other fields. It is on track to be applied and tested in the Spring/Summer of 2021. 
• Dr. Andrea Aagesen, PM&R’s Physician Builder, is helping to develop a process to use smart lists as an option for documentation in order to produce extractable, discrete data. The goal of this effort is to have a feasible option for documentation that is flexible, easily implemented, produces high quality data, and that can be built without requiring MiChart builders’ effort.
• The PM&R LHS team established the PM&R LHS Data Planning Team and began development of Data Governance Guidelines for the PM&R LHS based on the Michigan Medicine Data Governance Team’s standards and guidelines.
• Leadership of PM&R and the LHS is partnering with the Department of Learning Health Sciences and Michigan Medicine Leadership to identify the best methods for building our data infrastructure and creating institutional capabilities to support transforming clinical data into meaningful knowledge.

 Recap: Which LHS Teams have been established?

• NeuroSport and Concussion LHS Team
• Rehabilitation Psychology and Neuropsychology (RPN) Multiple Sclerosis LHS Team
• RPN Neuropsychology Assessment Clinic and Concussion Clinic LHS Team
• RPN General Psychotherapy Clinic LHS Team
• RPN Triage LHS Team
• Orthotics and Prosthetics (O&P) LHS Team
• Pelvic Floor Disorders LHS Team
• Spine LHS Team

What progress did the LHS Teams achieve this quarter?

NeuroSport & Concussion LHS Team

• Objective: This group is interested in better capturing patient and management information contained the medical record and tying it to patient recovery outcomes. Their goal is to analyze this information across all concussion patients seen in the NeuroSport and PM&R Concussion Clinics for quality improvement purposes, with eventual translation to clinical care through real-time integration of prognostic and management algorithms into MiChart to facilitate a more individualized discussion of treatment options and shared decision making with the patient, and ultimately improved outcomes.
• This Quarter’s Progress
  • Completed current state assessment of their clinical documentation and assessed the validity and reliability of data captured in the EMR 
  • Identified discrete data points needing to be captured
  • Successfully updated clinical documentation processes and are undergoing updates to new clinical templates
  • Conducted analyses using EMR-extracted data, and are submitting results for publication
  • Initiated REDCap database development for storage of EMR-extracted data

Rehabilitation Psychology and Neuropsychology (RPN) Multiple Sclerosis (MS) LHS Team

• Objective: This group is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports the clinical team in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and be presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Finalized list of standardized measures to be utilized for the MS clinic
  • Submitted measure build requests to MiChart for future implementation Began development of online administration of the Value-based activity planner tool

RPN Neuropsychology Assessment Clinic and Concussion Clinic LHS Team

• Objective: To digitize collection of patient reported outcome measure and neuropsychological assessment data into a single master database. Once the master database is created, the goal is to implement a process where individual patient assessment data is summarized into a summary report for physicians to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Finalized list of standardized measures to be utilized for the RPN Neuropsychology Assessment Clinic
  • Implemented new Concussion Databases (in REDCap) to collect patient data that supports the work of the RPN Concussion Recovery Groups

 RPN General Psychotherapy Clinic LHS Team

• Objective: This group is interested in incorporating patient reported outcome measures that provides important information about patient experience, tracks trends in the patient population, and supports psychologists in providing psychotherapy. The data collection and documentation will be standardized and structured to support quality improvement opportunities. The team’s goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Finalized list of standardized measures to be utilized for the RPN General Psychotherapy Clinic
  • Submitted measure build requests to MiChart for future implementation
  • Achieved team consensus to standardize data collection process

 RPN Triage LHS Team

• Objective: This workgroup is interested in utilizing REDCap as a database to assist in tracking referrals, triaging patients, and managing the RPN clinic waitlist.  Their goal is to create and incorporate a new REDCap database that will increase administrative documentation efficiency and be able to provide RPN leadership with up to date reports on patient flow, referrals, and waitlists.
• This Quarter’s Progress
  • Achieved team consensus to standardize scheduling and triaging data collection process
  • Team finalized creation of scheduling and triaging log utilizing REDCap in conjunction with MiChart

 Orthotics & Prosthetics (O&P) LHS Team

• Objective: This group is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Continued exploration of patient reported outcome measures to incorporate into their clinic data collection processes
  • Began investigation to update the O&P quality assurance reports process to produce meaningful O&P device production and delivery reports more frequently and efficiently

 Pelvic Floor Disorders LHS Team

• Objective: This workgroup was established as a collaboration among University of Michigan physicians and physical therapists from several departments (PM&R, OBGYN, and Urology) who treat patients with pelvic floor disorders. This team is interested in incorporating patient reported outcome measures that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Created draft of additional intake survey questions to assist with assigning patients in their shared clinic population to their starting clinic

 Spine LHS Team

• Objective: This team is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• This Quarter’s Progress
  • Selected patient reported outcome measures for the Spine Minimal Data Set and elective measures
  • Submitted the Spine Team Minimal Data Set measure build requests to MiChart for future implementation
  • Working to enhance the intake questions to be more patient-friendly and streamline the current patient intake form   

The purpose of this quarterly update is to provide all stakeholders with an update on the progress of the PM&R LHS project. 

What is the overall goal of the PMR LHS Project?

PM&R Learning Health System (LHS) Mission Statement: To learn from every patient by aligning clinical care, science, informatics, and culture, enabling continuous improvement and innovation in the practice of medical rehabilitation.

What are the attributes of a Learning Health System?

According to the Agency for Healthcare Research and Quality (AHRQ), the following are key attributes of Learning Health Systems:

• Having leaders who are committed to a culture of continuous learning and improvement
• Systematically gathering and applying evidence in real-time to guide care
• Employing IT methods to share new evidence with clinicians to improve decision-making
• Promoting the inclusion of patients as vital members of the learning team
• Capturing and analyzing data and care experiences to improve care
• Continually assessing outcomes, refining processes and training to create a feedback cycle for learning and improvement

What progress was made over the past quarter?

Listed below are several of the major accomplishments from the past extended quarter (April-July 2020):

• The PM&R LHS Operations Team published the LHS Initiative Page to the PM&R Website.
• Jordan Affholter joined the team as the new LHS Project Senior Manager in April 2020.
• Eight LHS Teams have been “launched” during this quarter (Full list provided in the next section). The formation of each LHS Team formation follows a key tenet of Learning Health Systems known as learning communities: a collection of stakeholders who organize around a shared purpose to advance the implementation of evidence-based interventions in health care settings to address important problems or questions. LHS Teams consist of PM&R faculty and staff, the PM&R LHS Operations Team, and (when applicable) additional Michigan Medicine collaborators from other departments. 
• Continued close collaboration with the Department of Learning Health Sciences (DLHS) with the goal of sharing information, expertise, and collaborating on future projects and grants.
• Began initial planning for the PM&R LHS Data Warehouse, which will integrate patient-level EMR data, outcome measures, and external data as well and make it readily accessible to LHS Teams.

Which LHS Teams have been established?

• NeuroSport and Concussion LHS Team
• Rehabilitation Psychology and Neuropsychology (RPN) Multiple Sclerosis LHS Team
• RPN Neuropsychology Assessment Clinic and Concussion Clinic LHS Team
• RPN General Psychotherapy Clinic LHS Team
• RPN Triage LHS Team
• Orthotics and Prosthetics (O&P) LHS Team
• Pelvic Floor Disorders LHS Team
• Spine LHS Team

What progress did the LHS Teams achieve this quarter?

NeuroSport & Concussion LHS Team 

• Objective: This group is interested in better capturing patient and management information contained the medical record and tying it to patient recovery outcomes. Their goal is to analyze this information across all concussion patients seen in the NeuroSport and PM&R Concussion Clinics for quality improvement purposes, with eventual translation to clinical care through real-time integration of prognostic and management algorithms into MiChart to facilitate a more individualized discussion of treatment options and shared decision making with the patient, and ultimately improved outcomes.
• Progress to Date
  • Team formed and objectives identified
  • Completed current state assessment of their clinical documentation and assessed the validity and reliability of data captured in the EMR
  • Identified discrete data points needing to be captured
  • Successfully updated clinical documentation processes and have begun use of new clinical templates
  • Conducted analyses using EMR-extracted data, and are submitting results for publication

Rehabilitation Psychology and Neuropsychology (RPN) Multiple Sclerosis (MS) LHS Team

• Objective: This group is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports the clinical team in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and be presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • Team formed and objective identified
  • Completed current state assessment of their clinical documentation and patient reported outcome measures that are utilized as part of the MS clinic process
  • Identified several new patient questionnaires to include for the clinic evaluations
  • Began investigation on how to incorporate new measures into MiChart and how the measure data can be automated into the clinician note template 

RPN Neuropsychology Assessment Clinic and Concussion Clinic LHS Team

• Objective: To digitize collection of patient reported outcome measure and neuropsychological assessment data into a single master database. Once the master database is created, the goal is to implement a process where individual patient assessment data is summarized into a summary report for physicians to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • Team formed and objective identified
  • Completed initial current state assessment of their clinical documentation and patient reported outcome measures that are utilized as part of the RPN clinic process
  • Implemented improved intake process to now allow families to submit comprehensive patient history data digitally to the attending psychologist before their clinic appointment. This information provides the clinical team with necessary patient history information to support the neuropsychological assessments. 
  • Identified several new patient questionnaires to include for the clinic evaluations.
  • Began investigation in order to administer questionnaires digitally through other systems such as REDCap or through the measure developer website.
  • Began development of a crosswalk for the historical Neuropsychology Assessment Clinic databases and the new master database. 

RPN General Psychotherapy Clinic LHS Team

• Objective: This group is interested in incorporating patient reported outcome measures that provides important information about patient experience, tracks trends in the patient population, and supports psychologists in providing psychotherapy. The data collection and documentation will be standardized and structured to support quality improvement opportunities. The team’s goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • Team formed and objective identified
  • Completed initial current state assessment of their clinical documentation and patient reported outcome measures that are utilized as part of the RPN clinic process
  • Identified several new patient questionnaires to include for the clinic evaluations.
  • Began investigation on how to incorporate additional measures into MiChart and how the measure data can be automated into the clinician note template. 

RPN Triage LHS Team

• Objective: This workgroup is interested in utilizing REDCap as a database to assist in tracking referrals, triaging patients, and managing the RPN clinic waitlist.  Their goal is to create and incorporate a new REDCap database that will increase administrative documentation efficiency and be able to provide RPN leadership with up to date reports on patient flow, referrals, and waitlists.
• Progress to Date
  • Team formed and objective identified
  • Completed current state assessment of their scheduling and triage documentation and identified areas for improvement in the current scheduling and triage spreadsheet
  • Identified discrete data points necessary to capture data related to patient classification, triaging patients, clinic scheduling, and patient waitlist status. The RPN administrator worked with the PM&R LHS REDCap database builder to develop a database that can capture these discrete data points.
  • The new RPN Triage REDCap database has been created and is currently undergoing testing to review functionality. 

Orthotics & Prosthetics (O&P) LHS Team

• Objective: This group is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • Team formed and objective identified
  • Began investigation of the current state assessment of their clinical documentation and data collection processes
  • Began investigation of potential patient reported outcome measures to incorporate into their clinic data collection processes 

Pelvic Floor Disorders LHS Team

• Objective: This workgroup was established as a collaboration among University of Michigan physicians and physical therapists who treat patients with pelvic floor disorders. This team is interested in collaborating among departments (PM&R, OBGYN, and Urology) to improve their triage process so that patients can receive more timely treatment. This team is also interested in incorporating patient reported outcome measures that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • Team formed and objective identified
  • Began investigation of the current state assessment of their clinical documentation, triage process, and patient population
  • Began collaboration with the Department of Obstetrics and Gynecology and the Department of Urology as part of the Pelvic Floor Disorders LHS Team work 

Spine LHS Team

• Objective: This team is interested in incorporating patient reported outcome measure data that provides important information about patient experience, tracks trends in the patient population, and supports physicians in providing clinical care. The data collection and documentation will be standardized and structured to support quality improvement opportunities. Their goal is to have this information analyzed across all patients to measure effectiveness of treatment, and presented in a way that is integrated into MiChart to enable discussion around treatment options and shared decision making with the patient.
• Progress to Date
  • In a collaboration between the Spine and Musculoskeletal (MSK) clinics, the Spine LHS Team has been investigating potential patient reported outcome measures (PROMs) to incorporate as part of the clinical processes over the past year. The goal of aligned PROM data collection is to provide the ability for physicians to track patient population trends and to review the effectiveness and impact of the treatment on patient function and quality of life.  
  • During this past quarter, Spine and MSK physicians completed Round 2 of the Spine LHS Team Delphi Survey in order to establish consensus on which PROMs to utilize. The Spine LHS Team is compiling the survey results and will be sharing the results with the Spine and MSK physicians in the upcoming weeks.
  • Completed investigation of potential updates to the triage process and reported results to PM&R Leadership
  • Began investigation on how to best incorporate new PROMs and clinician note template data in MiChart