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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
Results
1 to 25 of 31 Research Studies Displayed
Bradford A, Shofer M, Singh H
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
This paper discusses Measure Dx, a new AHRQ resource that translates knowledge from diagnostic measurement research into actionable recommendations. This resource guides healthcare organizations to detect, analyze, and learn from diagnostic safety events as part of a continuous learning and feedback cycle. The goal of Measure Dx is to advance new frontiers in reducing preventable diagnostic harm to patients.
AHRQ-authored; AHRQ-funded; 233201500022I; HS027363.
Citation:
Bradford A, Shofer M, Singh H .
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
Int J Qual Health Care 2022 Sep 10;34(3). doi: 10.1093/intqhc/mzac068..
Keywords:
Diagnostic Safety and Quality, Patient Safety, Quality Improvement, Quality of Care, Electronic Health Records (EHRs), Health Information Technology (HIT), Health Systems, Learning Health Systems
Bierman AS, Tong ST, McNellis RJ
Realizing the dream: the future of primary care research.
In this article, the authors discussed the primary care research central to successful primary care transformation and to realizing the vision of a high-performing US health system to serve effectively all Americans and their communities while advancing health equity.
AHRQ-authored.
Citation:
Bierman AS, Tong ST, McNellis RJ .
Realizing the dream: the future of primary care research.
Ann Fam Med 2022 Mar-Apr;20(2):170-74. doi: 10.1370/afm.2788..
Keywords:
Primary Care, Healthcare Delivery, Evidence-Based Practice, Health Systems, Learning Health Systems, Patient-Centered Healthcare
Pestka DL, White KM, DeRoche KK
'Trying to fly the plane while we were building it'. applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study.
This study’s objective was to examine the use of a learning health system (LHS) in primary care transformation (PCT) by utilizing the Consolidated Framework for Implementation Research (CFIR) to categorize implementation lessons. A large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics in May 2019. Semistructured qualitative interviews were conducted and observational field notes were taken. Inductive coding of the data was performed, and resultant codes were mapped to the CFIR. Seventeen codes emerged to describe care team members from the two clinics to adopt PCT occurring in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the ‘inner setting’ domain.
AHRQ-funded; HS026379.
Citation:
Pestka DL, White KM, DeRoche KK .
'Trying to fly the plane while we were building it'. applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study.
BMJ Open 2022 Jan 3;12(1):e053209. doi: 10.1136/bmjopen-2021-053209..
Keywords:
Learning Health Systems, Health Systems, Primary Care, Practice Improvement
Henriksen K, Rodrick D, Grace EN
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
This article describes a grant initiative undertaken by AHRQ that brings design, systems engineering, and health care delivery research together to test new ideas that could make health care safer. Based on feedback received from project teams, lessons learned are emerging that find considerable variation among project teams in deploying the methodology and a longer-than-anticipated amount of time in bringing team members from different disciplines together where they learn to communicate and function as a team. Three narratives are generated in terms of what success might look like.
AHRQ-authored.
Citation:
Henriksen K, Rodrick D, Grace EN .
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
J Patient Saf 2021 Dec 1;17(8):e1685-e90. doi: 10.1097/pts.0000000000000577..
Keywords:
Patient Safety, Healthcare Delivery, Learning Health Systems, Health Systems
Austin EJ, LeRouge C, Lee JR
A learning health systems approach to integrating electronic patient-reported outcomes across the health care organization.
The authors reported on their effort to develop generalizable learnings that can support the integration of electronic patient-reported outcome measures into clinical practice within a learning health system (LHS) framework. They concluded that the guidelines produced from this work highlighted the complex, multidisciplinary nature of implementing change within LHS contexts, as well as the value of action research approaches to enable rapid, iterative learning that leverages the knowledge and experience of communities of practice.
AHRQ-funded; HS023785.
Citation:
Austin EJ, LeRouge C, Lee JR .
A learning health systems approach to integrating electronic patient-reported outcomes across the health care organization.
Learn Health Syst 2021 Oct;5(4):e10263. doi: 10.1002/lrh2.10263..
Keywords:
Learning Health Systems, Health Information Technology (HIT), Patient-Centered Outcomes Research, Outcomes, Evidence-Based Practice
Atkinson MK, Singer SJ
Managing organizational constraints in innovation teams: a qualitative study across four health systems.
This study examined how interdisciplinary teams are affected by and manage external constraints over the lifecycle of their innovation project. The authors used a multimethod qualitative approach consisting of over 3 years of participant observation data to analyze how four interdisciplinary teams across different health system experienced and managed constraints as they pursued process innovations. Their findings point to several practical implications concerning innovation processes in healthcare: 1) how conditions in the organizational context, or constraints, can impede team progress at different stages of innovation; and 2) the collective efforts, or tactics, teams use to manage or work around those constraints to further progress on their innovations.
AHRQ-funded; HS024453.
Citation:
Atkinson MK, Singer SJ .
Managing organizational constraints in innovation teams: a qualitative study across four health systems.
Med Care Res Rev 2021 Oct;78(5):521-36. doi: 10.1177/1077558720925993..
Keywords:
Learning Health Systems, Health Systems, Innovations and Emerging Issues, Teams
Subash M, Liu LH, DeQuattro K
The Development of the Rheumatology Informatics System for Effectiveness Learning Collaborative for improving patient-reported outcome collection and patient-centered communication in adult rheumatology.
Patient-reported outcomes (PROs) are an integral part of treat-to-target approaches in managing rheumatoid arthritis (RA). In clinical practice, however, routine collection, documentation, and discussion of PROs with patients are highly variable. In this paper, the investigators discussed the Development of the Rheumatology Informatics System for Effectiveness Learning Collaborative for improving patient-reported outcome collection and patient-centered communication in adult rheumatology.
AHRQ-funded; HS025638.
Citation:
Subash M, Liu LH, DeQuattro K .
The Development of the Rheumatology Informatics System for Effectiveness Learning Collaborative for improving patient-reported outcome collection and patient-centered communication in adult rheumatology.
ACR Open Rheumatol 2021 Oct;3(10):690-98. doi: 10.1002/acr2.11310..
Keywords:
Arthritis, Patient-Centered Outcomes Research, Learning Health Systems, Health Information Technology (HIT)
Siddique SM, Tipton K, Leas B
Interventions to reduce hospital length of stay in high-risk populations: a systematic review.
Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. The objective of this study was to identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS.
AHRQ-funded; 75Q80120D00002.
Citation:
Siddique SM, Tipton K, Leas B .
Interventions to reduce hospital length of stay in high-risk populations: a systematic review.
JAMA Netw Open 2021 Sep;4(9):e2125846. doi: 10.1001/jamanetworkopen.2021.25846..
Keywords:
Learning Health Systems, Health Systems, Evidence-Based Practice, Hospital Discharge, Risk, Inpatient Care, Care Management
Bishop JR, Huang RS, Brown JT
Pharmacogenomics education, research and clinical implementation in the state of Minnesota.
This article looks at the development and implementation of formal pharmacogenomic (PGx) clinical programs at several healthcare organizations across Minnesota. These programs increase drug safety and effectiveness. The article reviews the state of PGx activities in the state of Minnesota including educational programs, research, national consortia involvement, technology, clinical implementation and utilization and reimbursement, and outlines the challenges and opportunities in equitable implementation of these activities.
AHRQ-funded; HS026379.
Citation:
Bishop JR, Huang RS, Brown JT .
Pharmacogenomics education, research and clinical implementation in the state of Minnesota.
Pharmacogenomics 2021 Jul;22(11):681-91. doi: 10.2217/pgs-2021-0058..
Keywords:
Medication, Implementation, Learning Health Systems, Evidence-Based Practice, Patient-Centered Outcomes Research
Yano EM, Resnick A, Gluck M
Accelerating learning healthcare system development through embedded research: career trajectories, training needs, and strategies for managing and supporting embedded researchers.
Health systems and organizations seeking to achieve learning healthcare system principles are increasingly relying on embedded research teams to optimize delivery of evidence-based, high-quality care that improves patient and staff experience alike. In February 2018, 115 attendees from multiple agencies, institutions and professional societies participated in a conference to accelerate development of learning healthcare systems through embedded research. This paper describes the process.
AHRQ-authored.
Citation:
Yano EM, Resnick A, Gluck M .
Accelerating learning healthcare system development through embedded research: career trajectories, training needs, and strategies for managing and supporting embedded researchers.
Healthc 2021 Jun;8(Suppl 1):100479. doi: 10.1016/j.hjdsi.2020.100479..
Keywords:
Learning Health Systems, Health Systems, Health Services Research (HSR)
Harrison MI, Shortell SM
Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation.
The authors have developed a comprehensive, multilevel framework to inform learning health systems (LHSs) research and practice in order to enhance both research on LHSs and practical steps toward their development. Drawing on the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework, their new framework can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors.
AHRQ-authored.
Citation:
Harrison MI, Shortell SM .
Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation.
Learn Health Syst 2021 Apr;5(2):e10226. doi: 10.1002/lrh2.10226..
Keywords:
Learning Health Systems, Health Systems, Implementation, Organizational Change
Graves JA, Nshuti L, Everson J
Breadth and exclusivity of hospital and physician networks in US insurance markets.
The goal of this study was to quantify network breadth and overlap among primary care physician (PCP), cardiology, and general acute care hospital networks for employer-based (large group and small group), individually purchased (marketplace), Medicare Advantage (MA), and Medicaid managed care (MMC) plans. The main outcomes measured were percentage of in-network physicians and/or hospitals within a 60-minute drive from a hypothetical patient in a given zip code (breadth), and the number of physicians and/or hospitals within each network that overlapped with other insurers' networks, expressed as a percentage of the total possible number of shared connections (exclusivity). Networks were categorized by network breadth size and analyzed by insurance type, state, and insurance, physician, and/or hospital market concentration level, as measured by the Hirschman-Herfindahl index. Markets with concentrated primary care and insurance markets had the broadest and least exclusive primary care networks among large-group commercial plans. Markets with the least concentration had the narrowest and most exclusive networks. Rising levels of insurer and market concentration were associated with broader and less exclusive healthcare networks. The authors suggest that this means that patients could switch to a lower-cost, narrow network plan without losing-in-network coverage to their PCP.
AHRQ-funded; HS025976; HS026395.
Citation:
Graves JA, Nshuti L, Everson J .
Breadth and exclusivity of hospital and physician networks in US insurance markets.
JAMA Netw Open 2020 Dec;3(12):e2029419. doi: 10.1001/jamanetworkopen.2020.29419..
Keywords:
Health Insurance, Learning Health Systems, Health Systems, Primary Care, Hospitals, Healthcare Delivery
Hernandez AV, Roman YM, White CM
Developing criteria and associated instructions for consistent and useful quality improvement study data extraction for health systems.
This paper describes AHRQ’s efforts to collate and assess quality improvement studies to support learning health systems (LHS). The authors identified quality improvement studies and evaluated the consistency of data extraction from two experienced independent reviewers at three time points: baseline, first revision, and final revision. Six investigators looked at the data extracted by the independent reviewers and determined the extent of similarity on a scale of 0 to 10. Two LHS participants were then asked to assess the relative value of their criteria. The consistency of extraction improved from a mean 1.17 score at baseline to 6.07 at first revision, and 6.81 at the final revision. There was not a significant improvement from the first to final revision. However, the LHS participants rated the value of these ratings a 9 and a 6, demonstrating that there is value in developing criteria.
AHRQ-funded; 290201500012I.
Citation:
Hernandez AV, Roman YM, White CM .
Developing criteria and associated instructions for consistent and useful quality improvement study data extraction for health systems.
J Gen Intern Med 2020 Nov;35(Suppl 2):802-07. doi: 10.1007/s11606-020-06098-1..
Keywords:
Quality Improvement, Quality of Care, Learning Health Systems, Health Systems, Health Services Research (HSR), Research Methodologies
Lin JS, Murad MH, Leas B
A narrative review and proposed framework for using health system data with systematic reviews to support decision-making.
This paper addresses when and how the use of health system data might make systematic reviews more useful to decisionmakers. The authors have developed a framework to guide the use of health system data alongside systematic reviews based on a narrative review of the literature and empirical experience. They recommend future methodological work on how best to handle internal and external validity concerns of health system data in the context of systematically reviewed data and work on developing infrastructure to do this type of work.
AHRQ-funded; 290201500007I; 29032001T05; 290201500005I; 290201500009I.
Citation:
Lin JS, Murad MH, Leas B .
A narrative review and proposed framework for using health system data with systematic reviews to support decision-making.
J Gen Intern Med 2020 Jun;35(6):1830-35. doi: 10.1007/s11606-020-05783-5..
Keywords:
Learning Health Systems, Health Systems, Evidence-Based Practice, Data, Decision Making
Richesson RL, Bray BE, Dymek C
Summary of second annual MCBK public meeting: mobilizing computable biomedical knowledge-a movement to accelerate translation of knowledge into action.
The Mobilizing Computable Biomedical Knowledge (MCBK) community formed in 2016. This report summarizes the main outputs of the Second Annual MCBK public meeting, which was held at the National Institutes of Health on July 18-19, 2019 and brought together over 150 participants from various domains to frame and address important dimensions for mobilizing CBK.
AHRQ-authored.
Citation:
Richesson RL, Bray BE, Dymek C .
Summary of second annual MCBK public meeting: mobilizing computable biomedical knowledge-a movement to accelerate translation of knowledge into action.
Learn Health Syst 2020 Apr;4(2):e10222. doi: 10.1002/lrh2.10222..
Keywords:
Implementation, Evidence-Based Practice, Learning Health Systems
Guise JM, Reid E, Fiordalisi CV
AHRQ series on improving translation of evidence: progress and promise in supporting learning health systems.
The authors discuss the articles in the AHRQ EPC series published in this journal over the past six months. They state that satisfaction, care, and costs would all improve if health care delivery were as efficient and effective as possible given current knowledge. They conclude that millions of health decisions must be made by clinicians, patients, and health care systems, and they believe better decisions will be made with evidence.
AHRQ-authored; AHRQ-funded; 290201700003C.
Citation:
Guise JM, Reid E, Fiordalisi CV .
AHRQ series on improving translation of evidence: progress and promise in supporting learning health systems.
Jt Comm J Qual Patient Saf 2020 Jan;46(1):51-52. doi: 10.1016/j.jcjq.2019.10.008..
Keywords:
Implementation, Evidence-Based Practice, Learning Health Systems, Health Systems, Healthcare Delivery, Decision Making
Borsky AE, Savitz LA, Bindman AB
AHRQ series on improving translation of evidence: perceived value of translational products by the AHRQ EPC Learning Health Systems Panel.
This paper discusses the outcomes of an evaluation of translational products for clinicians and healthcare providers by an EPC (Evidence-based Practice Center) Learning Health Systems Panel convened by AHRQ. The panel, led by two national leaders and composed of key stakeholders evaluated different translational products for learning health systems and also discussed challenges in adopting evidence-based practices. They evaluated a number of different products, and decided that the one- and three-page summaries, the MAGICapp and Tableau for interactive data visualization, and clinical encounter and health system decision aids were the most useful products. As a result of their findings, the EPC Program is further developing the one- and three-page summaries and MAGICapp and Tableau data visualization products.
AHRQ-authored; AHRQ-funded; 233201500014I.
Citation:
Borsky AE, Savitz LA, Bindman AB .
AHRQ series on improving translation of evidence: perceived value of translational products by the AHRQ EPC Learning Health Systems Panel.
Jt Comm J Qual Patient Saf 2019 Nov;45(11):772-78. doi: 10.1016/j.jcjq.2019.08.002..
Keywords:
Implementation, Evidence-Based Practice, Patient-Centered Outcomes Research, Learning Health Systems
White CM, Coleman CI, Jackman K
AHRQ series on improving translation of evidence: linking evidence reports and performance measures to help learning health systems use new information for improvement.
This paper analyzed ways to enhance usability of AHRQ’s Evidence-based Practice Center (EPC) reports. The reports are often lengthy and difficult for users to navigate. A quality measure index was created to allow health systems to more efficiently access relevant information. A test was created where two tables were embedded in an EPC report. The first identified quality measures covered by the report descriptively. The second contained page numbers in the executive summary which hyperlinked to those pages with the quality measures. An exercise with two health system-targeted scenarios was then created. The participants were timed how long it took to find answers to scenario questions and gave feedback. It was found that it took 63.4% less time to find quality measure information with the hyperlinked indexing tables than without. The participants felt that the tables were easy to use and more user friendly to health systems.
Jt Comm J Qual Patient Saf 2019 Oct;45(10):706-10. doi: 10.1016/j.jcjq.2019.05.002.
Citation:
White CM, Coleman CI, Jackman K .
AHRQ series on improving translation of evidence: linking evidence reports and performance measures to help learning health systems use new information for improvement.
Jt Comm J Qual Patient Saf 2019 Oct;45(10):706-10. doi: 10.1016/j.jcjq.2019.05.002..
Keywords:
Implementation, Evidence-Based Practice, Health Systems, Learning Health Systems, Patient-Centered Outcomes Research, Provider Performance, Quality Measures, Quality Improvement, Quality of Care
Fiordalisi C, Borsky A, Chang S
AHRQ EPC series on improving translation of evidence into practice for the learning health system: introduction.
This article introduces a special series of articles summarizing the AHRQ EPC program’s work to improve translation of high-quality evidence into practice. The authors summarize each of the nine EPC pilot projects and characterize the chosen approach to improve uptake of EPC review findings. They anticipate that the articles in this series will inform health systems about how others have tried to improve the translation of evidence into practice and use this information to inform their own efforts to bridge the evidence-to-practice gap going forward.
AHRQ-authored; AHRQ-funded; 290201700003C.
Citation:
Fiordalisi C, Borsky A, Chang S .
AHRQ EPC series on improving translation of evidence into practice for the learning health system: introduction.
Jt Comm J Qual Patient Saf 2019 Aug;45(8):558-65. doi: 10.1016/j.jcjq.2019.05.006..
Keywords:
Evidence-Based Practice, Learning Health Systems, Implementation, Quality Improvement, Quality of Care
Borsky AE, Flores EJ, Berliner E
Next steps in improving healthcare value: AHRQ Evidence-based Practice Center Program-applying the knowledge to practice to data cycle to strengthen the value of patient care.
This paper discusses AHRQ’s Evidence-based Practice Center (EPC) Program which has been in existence for over 20 years. The EPC program and its objectives are described. The three phases of the Learning Healthcare System cycle is described. A sample topic (hospital medicine Clostridium difficile colitis prevention and treatment) is used to describe the process and results of the effectiveness of the EPC program.
AHRQ-authored.
Citation:
Borsky AE, Flores EJ, Berliner E .
Next steps in improving healthcare value: AHRQ Evidence-based Practice Center Program-applying the knowledge to practice to data cycle to strengthen the value of patient care.
J Hosp Med 2019 May;14(5):311-14. doi: 10.12788/jhm.3157..
Keywords:
Evidence-Based Practice, Learning Health Systems, Implementation, Value
Adler-Milstein J, Nong P, Friedman CP
Preparing healthcare delivery organizations for managing computable knowledge.
This article describes results of an AHRQ-funded conference where a group of experts from a range of fields examined the current state of knowledge management in healthcare delivery organizations. Conference presentations and discussions were recorded and analyzed by the authors in order to identify foundational concepts. The concepts identified are: the current state of knowledge management in healthcare delivery organizations is reliant upon an outdated biomedical library model, and only a small number of organizations have developed management approaches to push knowledge in computable form to frontline decisions; Learning Health Systems create a need for scalable computable knowledge management approaches; the ability to represent data science discoveries in computable form that are findable, accessible, interoperable, and reusable is fundamental to spreading knowledge at scale.
AHRQ-funded; HS025316.
Citation:
Adler-Milstein J, Nong P, Friedman CP .
Preparing healthcare delivery organizations for managing computable knowledge.
Learn Health Syst 2019 Apr;3(2):e10070. doi: 10.1002/lrh2.10070..
Keywords:
Healthcare Delivery, Learning Health Systems, Organizational Change, Health Systems
Guise JM, Savitz LA, Friedman CP
Mind the gap: putting evidence into practice in the era of learning health systems.
This paper discusses two main mechanisms to close the evidence-to-practice gap: (1) integrating Learning Health System (LHS) results with existing systematic review evidence and (2) providing this combined evidence in a standardized, computable data format.
AHRQ-funded; 29020120004C.
Citation:
Guise JM, Savitz LA, Friedman CP .
Mind the gap: putting evidence into practice in the era of learning health systems.
J Gen Intern Med 2018 Dec;33(12):2237-39. doi: 10.1007/s11606-018-4633-1..
Keywords:
Evidence-Based Practice, Healthcare Delivery, Learning Health Systems, Implementation
Davis MM, Lindberg P, Cross S
Aligning systems science and community-based participatory research: a case example of the Community Health Advocacy and Research Alliance (CHARA).
In this article, the investigators explored opportunities to utilize concepts from systems science to understand the development, evolution, and sustainability of 1 community-based participatory research partnership: The Community Health Advocacy and Research Alliance (CHARA). Their goal was to highlight CHARA as a case for applying the complementary approaches of CBPR and systems science to (1) improve academic/community partnership functioning and sustainability, (2) ensure that research addresses the priorities and needs of end users, and (3) support more timely application of scientific discoveries into routine practice.
AHRQ-funded; HS022981.
Citation:
Davis MM, Lindberg P, Cross S .
Aligning systems science and community-based participatory research: a case example of the Community Health Advocacy and Research Alliance (CHARA).
J Clin Transl Sci 2018 Oct;2(5):280-88. doi: 10.1017/cts.2018.334..
Keywords:
Learning Health Systems, Research Methodologies
Harrison MI, Grantham S
Learning from implementation setbacks: identifying and responding to contextual challenges.
The authors addressed organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. They found that redesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped-for gains in operational metrics; however, team redesign was leading to improvements in chronic care and prevention and eased provider burden. Redesign and system leaders engaged in more thorough organizational learning. Their responses to challenges helped to strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value-based care and population health.
AHRQ-authored; AHRQ-funded; 2902010000341.
Citation:
Harrison MI, Grantham S .
Learning from implementation setbacks: identifying and responding to contextual challenges.
Learn Health Syst 2018 Oct;2(4):e10068. doi: 10.1002/lrh2.10068..
Keywords:
Organizational Change, Learning Health Systems, Health Systems, Primary Care: Models of Care, Primary Care, Ambulatory Care and Surgery, Implementation
Forrest CB, Chesley FD, Tregear ML
Development of the learning health system researcher core competencies.
The purpose of this study was to develop core competencies for learning health system (LHS) researchers to guide the development of training programs. The investigators found that the iterative development process yielded seven competency domains: (1) systems science; (2) research questions and standards of scientific evidence; (3) research methods; (4) informatics; (5) ethics of research and implementation in health systems; (6) improvement and implementation science; and (7) engagement, leadership, and research management.
AHRQ-authored; AHRQ-funded; 290201200017I.
Citation:
Forrest CB, Chesley FD, Tregear ML .
Development of the learning health system researcher core competencies.
Health Serv Res 2018 Aug;53(4):2615-32. doi: 10.1111/1475-6773.12751..
Keywords:
Education: Continuing Medical Education, Learning Health Systems, Training
