The Imperative for Learning Health Systems to Address Health Literacy

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By Cindy Brach, MPP, Senior Health Care Researcher, Agency for Healthcare Research and Quality and Bernard Rosof, MD, Chair of the National Academies of Sciences, Engineering and Medicine’s Roundtable on Health Literacy

“Learn or perish” would be an apt slogan for health systems today. The rate of change in health care is high. Technological advancements, research, innovation, and market dynamics all drive the soaring complexity of the health care system. In order to survive, health systems must learn how to adapt, and in the process – we argue – address health literacy. 

Integrating Knowledge into Practice 

One aspect of a learning health system (LHS), according to the charter and vision of the Institute of Medicine’s (IOM) Roundtable on Evidence-Based Medicine, is “to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider.” This means that integrating new knowledge into practice, the portion of the learning cycle depicted above that is highlighted by the red arrow, requires adaptation to the unique context of patients and their families.  

The current model of translating knowledge into practice consists of clinicians keeping up with the research literature, consulting the practice norms of their community, deciding which care is appropriate (i.e., “choosing wisely”), prescribing tests and treatment, with the expectation that patients will be compliant. As clinicians increasingly work for large health systems, care has become more standardized. Evidence reviews inform the development of clinical decision support tools, and performance metrics enable physicians to better understand their personal practice patterns and improve where necessary.  

Under the emergent LHS model, however, clinicians elicit patient goals and preferences, use data to tailor evidence to the patient, and engage in shared decision making. This requires physicians and the health care team to be clear communicators who engage and support patients and families as integral partners in medical decisions.  

Want To Engage Patients? Be Health Literate 

Engaging patients in their own health and health care fundamentally relies on health literacy—that is, their ability to obtain, process, communicate, and understand basic health information and services. Because many Americans have difficulty understanding health information as currently delivered, LHSs must reduce the cognitive demands placed on patients and the complexities of the health care system. To disrupt what has been called the cycle of crisis care, caused by the failure to deliver understandable information and simplify health care tasks, LHSs have to:  

  • Structure their delivery systems to take health literacy universal precautions, i.e., assume that all patients are at risk of not understanding. 
  • Educate their workforce in communication, engagement, and shared decision making skills so that they can clearly convey tailored evidence and help patients make informed choices that are congruent with their values and goals. 
  • Collect data to assess whether they are being health literate organizations that make it easier for people to navigate, understand, and use information and services to take care of their health. 

Ensuring Your System Has “Good Bones” 

Clinicians cannot provide health literate care without structural support. LHSs have to provide innovative solutions and restructure systems to make it easier for evidence-based care to be delivered. For example, a health system that learns to convey clinical information electronically can make the referral process easier for patients as well as for referring and receiving clinicians. Clinicians’ have to exercise leadership and champion the restructuring a LHS to hard wire health literacy universal precautions.  

Engaging Frontline Clinicians 

For LHSs to be successful, they have to engage their frontline clinicians, both convincing them to change their practices and giving them the skills to do so. Fortunately, there are health literacy tools that can help LHSs surmount the challenge of changing practice. These include: 

Let the Data Show You the Way 

LHSs are data driven. Sources of data that can inform a health system and guide practice transformation include: 

  • Health literacy organizational self-assessments that help the LHS identify and gain consensus about its strengths and weaknesses in the delivery of health literate care. 
  • Patient surveys that provide feedback that can be used to target quality improvement efforts. 
  • Operational measures that monitor whether new health literacy policies and practices are in fact being followed. 

Many health literacy data collection instruments and measures are catalogued in a paper commissioned by the National Academy of Sciences, Engineering and Medicine’s Roundtable on Health Literacy with support from Agency for Healthcare Research and Quality (AHRQ).  

Health Literacy, Trust, and the Quadruple Aim….A Pathway to the Future 

Fundamental to the relationship between the patient and the health care team is the establishment of mutual trust. That bond helps to ensure better care, improved outcomes and aligns the incentives of all. A barrier to the evolution of that trust is poor communication. Embracing health literate practices to communicate more effectively enables shared decision making, patient and family engagement, maximum patient satisfaction…and indeed clinician satisfaction. The National Academy of Medicine LHS series volume Patients Charting the Course: Citizen Engagement and the Learning Health System underscores the centrality of communication strategies that account for and engage individual perspectives, needs, preferences, understanding, and support necessary to mobilize change. This alignment of health literate practices to enhance communication and trust facilitates achieving the quadruple aim – enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. 

Embracing Health Literacy to Achieve the LHS Vision 

LHSs want to deliver patient-centered care, reduce medical errors, enhance quality, and improve health outcomes, and reduce cost to achieve affordable health care. Health care leaders increasingly recognize that this requires fully engaging patients in prevention, decision-making, and self-management activities. Addressing health literacy is an essential prerequisite to engaging patients. As stated in the above-mentioned NAM LHS volume, “the vision for a learning health system takes a broader view by making informed patients a central system goal. Achieving this goal requires medical evidence to be presented to patients in a form that is understandable and actionable, based on patient preferences, expectations, health concerns, and health literacy.” The sooner LHSs embrace health literacy strategies, the sooner they can reach this vision. 

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