Building a health system that can learn calls for “team science to the max”

Michael Mugavero, M.D., professor in the Division of Infectious Diseases, received HSF-GEF funding to launch the UAB Learning Health System project, where the people setting the research questions are not individual investigators with their own niche interests, “but the people in the trenches.”When COVID hit, Michael Mugavero, M.D., made a phone call. “What we did for HIV at 1917 Clinic in 2006 …” he said to longtime collaborator James Willig, M.D., “are you up for it for COVID and the Health System in 2020?”

That call started a project that culminated in the largest grant in the history of UAB’s 25-year-old Health Services Foundation General Endowment Fund program. Mugavero, professor in the Division of Infectious Diseases; director of UAB’s Center for Outcomes Effectiveness Research and Education, or COERE; associate director of the Center for Clinical and Translational Science, or CCTS; and co-director for the Center for AIDS Research, is the project’s principal investigator.

The concept for the UAB Learning Health System project “is that every day at UAB Medicine we see thousands of patients, and each creates opportunity for learning,” Mugavero said. “That allows us to provide better care for patients and the staff who see those patients and to learn how these lessons are generalizable outside UAB in Birmingham, Alabama and beyond.” In other words, Mugavero said, it is “leveraging the Health System as a research lab,” where the people setting the research questions are not individual investigators with their own niche interests, “but the people in the trenches.”

What is a learning health system? Mugavero likes the definition formulated by the federal Agency for Healthcare Research and Quality, which calls it “a system where internal data and experience are combined with external evidence, and that knowledge is put into practice.” The AHRQ definition also emphasizes the result: “Patients get higher-quality, safer, more efficient care, and health care delivery organizations become better places to work.”

In 2006, Mugavero returned to UAB (where he had done his residency) to join the faculty in Infectious Diseases. Working in the 1917 Clinic, UAB’s pioneering outpatient HIV clinic, Mugavero and Willig (now also a professor in Infectious Diseases) leveraged a database that linked patient medical records, biological specimens and patient-reported outcomes information. That allowed them to answer a range of questions, including: Which patients are more likely to miss their appointments, and why? What factors separate patients who do well from those who do poorly? And what are the best ways to engage patients in their medical care? “A lot of the questions we answered were from social workers and nurse practitioners — people doing the front-line work who had seen certain practices be effective and wanted to know how to expand them,” Mugavero said.

Mugavero, who led the clinical research core at the UAB Center for AIDS Research for a decade, saw how the funding provided by the federal Ryan White Care Act, with its emphasis on quality and safety work, had improved patient outcomes in HIV. When COVID appeared, there was no dedicated money at first; but everyone was energized to take part, including UAB Medicine leadership, Mugavero says. “It was all based on a call to action and goodwill, leveraging financial and human resources that already existed,” Mugavero said. Careful study of UAB’s COVID patient data that included co-principal investigator, Allyson Hall, Ph.D., professor in the Department of Health Services Administration in the School of Health Professions, pointed to modifications in wound care nursing practices to avoid hospital-acquired pressure injuries. Another example: “We had limited gloves and masks in those early days, so we started doing inpatient telehealth in the hospital with [UAB Medicine Chief Medical Officer] Dr. Kiersten Kennedy,” Mugavero said. “We quickly saw what worked and shared that information with our colleagues to inform patient care, and our data also led to researchers’ having success obtaining new grants and publishing manuscripts.”

COVID “really was a proof of concept” that Mugavero and colleagues could point to when they applied for HSF-GEF funding in 2021, he said. Their proposal was to build the infrastructure and platform to do what they had done with HIV and COVID on an institutional level. “This is about marrying the clinical and research arms of the medical school with the academic medicine arm,” Mugavero said. “This gave us the resources to think about what that would look like.”

Some of this work was being done, of course. “We did not want to create another unit that sits by itself, but to connect with people already doing this work,” Mugavero said. “If we create those structures and processes to think about access to data and regulatory issues, such as IRB approvals and data-use agreements, we can create a central platform so that, every time an investigator wants to do this, they do not have to recreate the wheel.” That also means thinking about the design, statistical models and measurements needed to know whether programs are working or whether they need to be modified or just dropped altogether. “The idea is rapid-cycle innovation, evaluation and translating knowledge to practice,” Mugavero said.

“If ever there were team science, this is team science to the max,” he said. “There are people from Medicine, Health Professions, Nursing, Public Health, College of Arts and Sciences, UAB Medicine vice presidents, quality and safety officers, and many others.”

Learning health systems are increasingly becoming table stakes in major grants. For one major NIH application, the instructions made clear that health systems that did not already have one set up need not apply. The HSF-GEF funding “helped put us on the map,” Mugavero said, and contributed to UAB’s selection to join the OneFlorida+ Clinical Research Network initiative out of the University of Florida, which is combining data from 10 health systems in Florida plus UAB and Emory University, which represent the Birmingham and Atlanta metro areas, for a total of more than 19 million patients.

“Now we can do this work across multiple health systems in multiple states, as part of a consortium that is eager for investigators to bring their best ideas informed by the insights from our front-line providers at UAB Medicine,” Mugavero said.