There was consensus among our participants that a Learning Healthcare System is about more than IT and informatics. Technical solutions alone or even journal articles and guidelines will not improve health outcomes (Munro 2015). This is demonstrated by the estimate that knowledge transfer, ďfrom bench to bedsideĒ, currently takes around 17 years (Friedman 2015).
ďTranslating the findings of data analysis and research into a change in practice can be a real challenge and the level of effort depends on what you are doing. If it is a simple process change it can be done quickly and efficiently, for example a formulary change has a level of effort of one. Introducing a new concept that begins to change behaviour, such as a guideline, increases that level of effort to about ten. Changes that go against peopleís beliefs move up to an effort level of one hundred. Asking a practitioner to change their own behaviour in a fundamentally different way, for example supporting shared decision making, may have a level of effort even higher than this.Ē (Wallace 2015)
The technology underpinning the Learning Healthcare System already exists but creating the culture of change has been cited as the harder problem to solve (Wallace 2015). It is not simply about delivering knowledge to the point of care, it is about ensuring that the knowledge results in a change in behaviour, by patients, clinicians, providers, commissioners and other actors, to improve outcomes (Bates 2015).
Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice (Fogarty International Center 2013). This must be an integral element of any Learning Healthcare System. Implementation science is a broad and developing field, but the issue most commonly cited by participants was change and this generally meant behavior change. A recent report from the Health Foundation identifies four barriers to making change (Allcock, Dormon et al. 2015):
ē Shortage of capability to make change
ē Insufficient Ďheadspaceí to make change
ē Lack of recognition that change is needed
ē Limited motivation for change
This and other models of change suggest general interventions that may help to overcome these barriers, however, most do not offer a systematic method for tailoring interventions to a particular context.
The Behaviour Change Wheel (BCW) (Figure 4) (Michie, van Stralen et al. 2011) is a systematic method for designing, implementing and evaluating behaviour change interventions in any setting. It is based on 19 existing theoretical frameworks. It offers a process that could be integrated with a Learning Healthcare System, to ensure that the insights generated by the informatics are translated into behaviour change and ultimately, improvement in health outcomes (the red side of the Cycle - Figure 2).
Figure 4: The Behaviour Change Wheel (Reproduced from Michie, van Stralen et al. 2011)
The hub of the BCW is concerned with understanding the behaviour that has to be changed. This is achieved using the COM-B model (Figure 2)
Figure 5: The COM-B Framework for understanding behaviour (Reproduced from Michie, van Stralen et al. 2011)
Changing the behaviour of an individual, group or population, requires a change in, capability, opportunity or motivation, or some combination of the three potential barriers that map neatly onto those identified above (Allcock, Dormon et al. 2015). Multiple methods can be employed to elicit this understanding from a range of stakeholders, depending on the nature of the behaviour and the resources available. For example, standardised questionnaires have already been developed (Michie, Atkins et al. 2014). Each element of the COM-B model has two sub-components as shown in the behaviour change wheel (Figure 4).
The next element of the wheel outlines the set of possible intervention functions (broad categories of means by which an intervention can change behaviour. These include, Education, Persuasion, Incentivisation, Coercion, Training, Enablement, Modelling, Environmental Restructuring and Restrictions (Michie, Atkins et al. 2014).
The BCW guide (Michie, Atkins et al. 2014) provides a matrix that links the COM-B model to the intervention functions (Michie, van Stralen et al. 2011). For example, if the barrier to behaviour change is Physical Capability, then Training and Enablement are two potential functions that the intervention could serve. If the barrier is Reflective Motivation, then the intervention could serve the functions of Education, Persuasion, Incentivisation and Coercion (or a combination of these).
The final element on the BCW is the set of possible policy categories; seven ways in which policy could deliver the intervention. These include, Communication/Marketing, Guidelines, Fiscal Measures, Regulation, Legislation, Environmental/Social Planning and Service Provision (Michie, Atkins et al. 2014). Again, a matrix has been created that links the intervention functions to the policy categories that are likely to be effective.
In order to operationalise the BCW, the intervention functions are linked to Behaviour Change Techniques (BCTs), which are the smallest, active components of an intervention, designed to change behaviour (e.g. self-monitoring, goal setting, action planning, etc.). A taxonomy of 93 techniques has been developed (Michie et al. 2013) which can be used to describe BCTs used in interventions. The most frequently used BCTs have been mapped onto the intervention functions of the BCW.
The BCW enables a theoretical and systematic approach to be taken to intervention design. The COM-B model can be used to analyse user data and help Ďdiagnoseí what needs to shift in order for change to occur. Guided by matrices in the BCW guide and a set of criteria (the ĎAPEASEí criteria), the most appropriate intervention functions, policy categories and BCTs for the context, behaviour and population of the intervention, can be selected (Michie, Atkins et al. 2014).
Elements of this process could be automated within a Learning Healthcare System and crucially, evidence could be collected on the effectiveness and cost effectiveness of each of the BCTs in various situations, resulting in further learning. There are already early examples of the BCW being integrated in the design of mHealth apps (Medicine 2.0 2014, West Midlands Health Informatics Network 2014)
Behaviour change will be required to enable patients, clinicians and organisations to adopt a Learning Healthcare System. It will also be required to ensure that they act on the evidence generated by the Learning Healthcare System, thus completing what Professor Freidman terms the red (or efferent) side of the cycle (Figure 1) (Friedman 2015).
The BCW is the only behaviour change framework that has been constructed from an analysis of existing frameworks and has been assessed in terms of its reliability in practice (Michie, van Stralen et al. 2011). If it is to improve healthcare outcomes, then any Learning Healthcare System must have a method of delivering behaviour change at its heart (Friedman 2015).
Professor Charles Friedman Interview
Author Dr Tom Foley, Dr Fergus Fairmichael
BackgroundProfessor Charles Friedman is Chair of the Department of Learning Health Sciences at the University of Michigan Medical School. He is the former Deputy National Coordinator and Chief ScientiLearn More ⇛
Dr James Munro Interview
Author Dr Fergus Fairmichael
BackgroundDr James Munro is chief executive and chief technology officer of Patient Opinion. He has a background in clinical medicine, public health and health services research.Patient Opinion was foLearn More ⇛
Mr Joshua Rubin Interview
Author Dr Tom Foley, Dr Fergus Fairmichael
BackgroundMr Joshua Rubin is the Program Officer for Learning Health System Initiatives at the Department of Learning Health Sciences, University of Michigan Medical School. Mr. Rubin is a formeLearn More ⇛
Dr David W Bates Interview
Author Dr Tom Foley, Dr Fergus Fairmichael
BackgroundDavid W. Bates, MD, MSc, is Senior Vice President and Chief Innovation Officer for Brigham and Womenís Hospital. He is a practicing general internist and maintains his positions as Chief ofLearn More ⇛
Dr Paul Wallace Interview
Author Dr Tom Foley, Dr Fergus Fairmichael
BackgroundPaul Wallace, MD, is Chief Medical Officer and Senior Vice President for Clinical Translation at Optum Labs. Before joining Optum Labs, Dr. Wallace was senior vice president and Director ofLearn More ⇛
Dr Caroline Wood Interview
Author Dr Tom Foley
BackgroundDr Caroline Wood is Assistant Director at the UCL Centre for Behaviour Change,
Dr Wood has kindly reviewed the behaviour change chapter of our report and offered many helpful additions.
Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characteris
Emotional Intelligence for expert patients The Self-Science Curriculum for expert patients The Seven Habits of Highly Effective People ‚ÄúInterdependence is a higher value than independence‚ÄĚ 1) Be proactive 2) Begin with the end in mind 3) Put first things first 4) Think win/win 5) Seek first to understand, then to be understood 6) Synergise 7) Balanced self renewal Knowledge Self-awareness Insight Skills Personal decision-making Managing feelings Handling stress Empathy Communication Self-disclosure Self-acceptance Activity and implementation Self appraisal and re-design Leadership of self Attitudes and practice and application Personal responsibility Assertiveness Group dynamics Conflict resolution Humour Expert patients need to understand what it means ‚Äď and how ‚Äď to bring intelligence to emotion. Education around record access will routinely include self-awareness, self control, empathy and the arts of listening, resolving conflicts and cooperation. Emotions are at the centre of aptitudes for living. Bad emotions (fear, anxiety, jealousy, hate) put physical health at as much risk as does chain smoking, even as emotional balance can help protect our health and well being. Ignorance plays a large part too. Mentally Healthy families 1) Positive in their attitude to life and other people. 2) The ‚Äėlove‚Äô of healthy families involves closeness and distance. They are capable of great intimacy and affection, but they also feel self-sufficient and confident and free. 3) They are very clearly in charge of the lives. 4) The members of the family are always consulted very fully. 5) They communicate well. They are straightforward ‚Äď direct and open and honest with each other. 6) They are very realistic and practical. 7) They have a remarkable ability to cope with change. Coping with Change 1) Rest. Patients need a period of time when they are relieved of as many demands as possible 2) Change of mind. Patients have to adapt their mental map to the changed world around them. They may need advice and information from people who have been through a similar experience and know how to cope with it. 3) Emotional support . - Good relationships that the family members enjoyed with each other - Good connection in the community. - Support from some kind of transcendental support system. Mature ways for patients to deal with emotions. - Anticipation - Suppression ‚Äď rather than repression ‚Äďhold it in check and bear the discomfort of feeling it. - Sublimation finding other ways of expressing problematic emotions and impulses which not only feel satisfying, but which are socially acceptable and perhaps creative. eg. Altruism - Humour Games People play ‚Äď Doctor and patient Patients (and doctors) get stuck in parts of their personality rather than using the whole part of it. Perceptions are deeply imbedded. They produce expectations and self-fulfilling prophecies. Patients and doctors interpret the world through a lens of perception and must occasionally look at the lens itself to understand the image that they see. Open and Close Functioning ‚ÄúOpen‚ÄĚ is when patients open themselves up to the world, take in new information and let it change their internal maps to make them more comprehensive and accurate. ‚ÄúClosed‚ÄĚ is when patients have changed their internal maps and decided that action has to be taken. Patients give their attention to achieving some goal.
Avoiding Defence Mechanisms Adapting to change is a two-stage process. First, we have to realise that some of our repeated responses to continuing change may be unhelpful; second, we need to explore and use new ways of coping until satisfactory solutions are found. You may sometimes hear social workers, counsellors and psychologists using words such as ‚Äėdenial‚Äô and ‚Äėrationalisation‚Äô to describe the way people respond to stress. These are technical terms which most people do not come across in everyday speech. I explain them briefly over the next page or so. ‚ÄĘ Some of these repeated, unhelpful responses ‚Äď defence mechanisms ‚Äď are described below. Remember, though, that these are only ideas that may help us understand ourselves by showing how our minds work and how we react to stress. ‚ÄĘ ‚ÄĘ Regression ‚Äď going back to the ways of thinking, feeling and behaving which are more appropriate to earlier stages of individual or social development. Thus an adult may regress to childish temper tantrums. ‚ÄĘ ‚ÄĘ Transference ‚Äď the experience of emotions towards one person which are derived from experience with another. For example, anxious or hostile feelings previously felt towards a domineering parent may, in later life, be felt in relation to figures in authority. ‚ÄĘ Projection ‚Äď the opposite of introjection, the displacement of personal attitudes on to others or the environment. This is another way of avoiding self-blame and guilt. Personal inadequacies are blamed on others or even on the environment. ‚ÄĘ Resistance ‚Äď a barrier between the unconscious and conscious mind, preventing the resolution of tensions or conflicts. For example, someone might unconsciously resist enquiring into the origins of his Change, thereby prolonging his condition. ‚ÄĘ ‚ÄĘ Displacement ‚Äď shifting an emotion from one target to another. Ideas or attitudes which make us uncomfortable may be disguised or avoided in this way. For example, anger with our workmates may be taken out on our families. ‚ÄĘ Rationalisation ‚Äď a form of self-deception in which socially acceptable reasons are found for conduct that is prompted by less worthy motives. ‚ÄĘ ‚ÄĘ Dissociation ‚Äď avoiding looking too closely at our attitudes so that inconsistencies in our thoughts and conduct are overlooked. ‚ÄĘ ‚ÄĘ Compensation ‚Äď a behaviour that is developed to offset a defect or sense of inferiority, for example, running a pet sanctuary to make up for poor human relationships. Thus overcompensation occurs when compensation is overdone. ‚ÄĘ Conversion ‚Äď hidden fears may be ‚Äėconverted‚Äô and come to the surface in the form of bodily symptoms. Someone who is afraid of going out may develop a weakness in the legs. ‚ÄĘ Denial ‚Äď persuading oneself that there is nothing really wrong when, in fact, there is. This is done in the hope that the trouble will somehow go away ‚Äď for example, refusing to admit that you are ill. ‚ÄĘ Withdrawal ‚Äď giving up, and physical and emotional retirement from a stressful situation, characterised by loss of enthusiasm and interest, apathy and daydreaming. ‚ÄĘ Fixation ‚Äď ‚Äėfixed‚Äô personal behaviour which is more appropriate to earlier, less mature periods. This is seen in grown adults who depend, child-like, on others. ‚ÄĘ Identification ‚Äď conscious or unconscious modelling of oneself on another person, which may include the assumption of his or her dress, leisure activities, etc. This may be quite normal: for example, young people often imitate the attitudes and behaviour of older people whom they hold in high regard. ‚ÄĘ Introjection ‚Äď the turning inwards on oneself of the feelings and attitudes towards others, which gives rise to conflict and aggression. Unspoken anger with other family members may then lead to self-harm. ‚ÄĘ Inversion ‚Äď the exaggeration of tendencies opposite to those that are repressed. Prudery, for example, may be an inversion of repressed sexual desire. ‚ÄĘ Repression - - the pushing out of consciousness of ideas and impulses that do not fit in with what the individual regards as correct in the circumstances. Repression is unconscious and involuntary, in contrast to suppression, which is the intentional refusal to have thoughts or feelings, or carry out actions that conflict with moral standards. ‚ÄĘ Sublimation ‚Äď the direction of undesirable or forbidden tendencies into more socially acceptable channels. For example, childish, self-indulgent behaviour is sublimated into entertaining or altruistic social behaviour in the process of maturity. Surplus energy may be sublimated into useful channels.
University of Oxford Department of educational studies Donald Mcintyre Principles and methods of adult learning ‚ÄúAdult learning‚ÄĚ is best understood not as a set of principles about what should happen, but as a set of descriptive generalisations about what does happen, whether we like it or not, together with some tentative suggestions about how such learning can be facilitated. Self-Concept. When a person begins to see himself not as primarily as a learner, but as an actor or doer in the world,(s)he acquires a new status in others‚Äô eyes but especially in his or her own eyes, and belief in self as a self-directing personality. The adult has a need to be treated as autonomous and worthy of respect. At the same time, most adults are not accustomed to directing their own learning in any systematic or disciplined way. They need to take responsibility for their learning; and having done so, frequently achieve great satisfaction from self-directed learning. Possible implications. Need for spirit of mutual respect between student and student, and appreciation of each other as people and colleagues; need for student to diagnose her own needs; joint planning of objectives to be obtained and of learning experiences to attain these; learning process also a collaborative enterprise; evaluation of learning by student. Reservoir of experience. The adult learner has had a great deal of experience with which any new experience can be compared and in relation to which any new experience will be understood. The adult tends to view and value himself or herself as a product of past experience, and therefore values that experience and is likely to feel unfairly humiliated by tasks which reject the relevance of that experience. Correspondingly, the adult tends to have established habits and patterns of thought which are not easily changed. Possible implications. Effective teaching methods are likely to be those that encourage the use of, and reflection upon, the experiences that an adult perceives to be relevant; new ideas should be exemplified in terms of adult learners‚Äô past experiences; adult learners need to recognise the way in which their thinking is bound by their new situations. Just as each individual is likely to have a different pattern of relevant experience, so their concerns and what they can bring to them are likely to be unique to each individual. Role of orientation in learning. Whereas children are motivated to learn by the opportunities for growth into general new understandings and for mastery of general new skills, adults tend to be most motivated by the need to meet the demands of new roles. Possible implications. The learning tasks that adults are asked to undertake should be directly related to the roles they are currently, or in the near future, being asked to fulfil. The performance of role models, especially when these are in realistic situations, are likely to be especially influential, although observation is likely to be of limited value without subsequent explanation of the significance of the model‚Äôs actions. Such modelling should be resented as offering additions to existing repertoires rather than as sufficient for automatic imitation. Practice in the role. And feedback on it, are other especially appropriate learning procedures. Immediacy of application. Adults generally learn not in preparation for some distant future but in order to meet present needs. They tend therefore to learn not according to the discipline of subjects but rather according to their problem-solving needs. Possible implications. The educator‚Äôs chance to influence the adult learner is by offering information of the kind that the learner needs to solve his or her problems. The information needed may be of many diverse kinds, will vary according to the distinctive learner. And will at best be assimilated to established ways of thinking, or modifying these, rather than replacing them.