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, “from bench to bedside”, currently takes around 17 years (Friedman 2015).
“Translating 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 people’s 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.” (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):
• Shortage of capability to make change
• Insufficient ‘headspace’ to make change
• Lack of recognition that change is needed
• 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 ‘diagnose’ what needs to shift in order for change to occur. Guided by matrices in the BCW guide and a set of criteria (the ‘APEASE’ 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).