Eugene C Nelson

Dartmouth College · Department of Community and Family Medicine & The Dartmouth Institute

The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnershi...

Objective: Dashboards can support person-centered care by helping people partner with their clinicians to coproduce care based on preferences, shared decision-making, and evidence-based treatments. We engaged caregivers of children with juvenile idiopathic arthritis (JIA), adults with rheumatoid arthritis (RA), and clinicians in a pilot study to a...

Introduction The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess...

Background Patient-reported outcomes—symptoms, treatment side effects, and health-related quality of life—are important to consider in chronic illness care. The increasing availability of health IT to collect patient-reported outcomes and integrate results within the electronic health record provides an unprecedented opportunity to support patients...

Objective Determine differences in utilization patterns, disease severity, and outcomes between patients with and without diabetes mellitus diagnosed with COVID-19 in 2020Research Design and Methods We used an observational cohort comprised of Medicare fee-for-service beneficiaries with a medical claim indicating a COVID-19 diagnosis. We performed...

Background Despite progress in developing learning health systems (LHS) and associated metrics of success, a gap remains in identifying measures to guide the implementation and assessment of the impact of an oncology LHS. Our aim was to identify a balanced set of measures to guide a person-centered oncology LHS. Methods A modified Delphi process a...

There is increasing interest in asking patients questions before their visits to elicit goals and concerns, which is part of the move to support the concept of coproducing care. The phrasing and delivery of such questions differs across settings and is likely to influence responses. This report describes a study that (i) used a three-level model to...

The findings of this body of work are presented in the eight articles included in this supplement. The impact and perspectives of adult and pediatric care teams and patient/families are covered with special attention to mental health care, the financial and personnel impacts within care programs, the experiences of vulnerable and underrepresented p...

Background COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, emerged in 2019 and led to a worldwide pandemic in 2020. The COVID-19 pandemic has been a massive natural experiment in the formation of mitigation strategies to prevent cases and to provide effective healthcare for those afflicted. Regional differences in the impact of the...

Introduction The greatest challenge confronting political, public health, business, education and social welfare leaders in the COVID pandemic era is to restore the economy, businesses and schools without further risking public health. The ‘COVID Compass’ project aims to provide helpful information to guide local decisions by tracking state and loc...

Background Coproduction of healthcare services by patients and professionals is seen as an increasingly important mechanism to support person-centred care delivery. Coproduction invites a deeper understanding of what persons sometimes called ‘patients’ bring to development of a service. Yet, little is known about tools that may help elicit that inf...

Introduction: There is significant variation in processes and outcomes of care for patients with inflammatory bowel disease (IBD), suggesting opportunities to improve quality of care. We aimed to determine whether a structured quality of care program can improve IBD outcomes, including the need for unplanned health care utilization. Methods: We...

Background: Coproduction of care involves patients and families partnering with their clinicians and care teams, with the premise that each brings their own perspective, knowledge, and expertise, as well as their own values, goals, and preferences to the partnership. Dashboards can display meaningful patient and clinical data to assess how a patie...

Background The IBD Qorus Collaborative aims to reduce variation and increase the value of care for the adult inflammatory bowel disease (IBD) community. To evaluate the success of the collaborative, we aimed to develop a balanced set of outcome measures that reflect a multistakeholder view of value in IBD care. To achieve this, we used the Clinical...

Background Health systems worldwide are experiencing increasing cost-cutting pressures with more intense competition and rising customer requirements. We aimed to find out and compare the characteristics and successes of two different sustainable business cases in healthcare delivery from an innovation-driven, organizational perspective. Subject a...

Ninety percent of health care systems now offer patient portals to access electronic health records (EHRs) in the United States, but only 15% to 30% of patients use these platforms. Using PubMed, the authors identified 53 studies published from September 2013 to June 2019 that informed best practices and priorities for future research on patient en...

Background Healthcare coproduction engages patients and clinicians to design and execute services, yet little is known about tools that facilitate coproduction. Our objective was to understand uptake, experiences, benefits, and limitations of a dashboard to support patient-clinician partnerships within the cystic fibrosis (CF) community. Methods P...

Background: New opportunities to record, collate, and analyze routine patient data have prompted optimism about the potential of learning health systems. However, real-life examples of such systems remain rare and few have been exposed to study. We aimed to examine the views of design stakeholders on designing and implementing a US-based registry-...

Background: While health systems worldwide are struggling with rising costs, inadequate coordination of care and rising customer requirements, some innovative business models have started to create value in health services delivery by scoring on all three triple aim measures – better health outcomes, better patient experience, and lower per capita...

Cystic fibrosis (CF) is a genetic disease in which dysfunction of a single protein channel leads to organ damage, resulting in chronic health problems and premature death. In the United States, medical care of individuals living with CF is delivered by care centers accredited and subsidized by the CF Foundation. CF outcomes have improved significan...

Background There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study o...

Patients at the center of care is often the stated focus of clinicians and healthcare services. The quality and safety movement has shown that effective organization of care is needed, in addition to professional skills. This movement has provided professionals and others with methods to improve both organization and practice for patients. These me...

A novel, comprehensive health risk index for adults has been validated and is now ready for use to improve the health of individuals and populations. This health risk index provides an estimate of the avoidable risk of death for adults 30 years or older. It includes 12 evidence-based clinical and behavioral risk factors and was validated on discrim...

The American Journal of Gastroenterology is published by Springer Nature on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological...

Large scale collection and analysis of data on patients’ experiences and outcomes have become staples of successful health systems worldwide. The systems go by various names—including registries, quality registries, clinical databases, clinical audits, and quality improvement programmes— but all collect standardised information on patients’ diagnos...

This work is supported by funding from the Robert Wood Johnson Foundation (Grants: #71211 and 72313), the Cystic Fibrosis Foundation (Grant #OCONNO04Q10), and the Crohn’s and Colitis Foundation of America Quality of Care Initiative (Grant #3372). TSM was funded by the Multidisciplinary Clinical Research Center for Musculoskeletal Diseases at Dartmo...

Scores of registries have been developed but few have evolved to become patient-centered learning systems in which patients, clinicians, and scientists partner to co-produce better health outcomes, improved healthcare services and patient-centered research.

First we present a case vignette. Mollie is a 50-year-old woman with chronic, disabling back and knee pain, who has struggled with depression and alcohol misuse, is the primary caregiver for her ailing mother and a newcomer to the community. As a primary care patient at Dartmouth Health Connect, whose mission is "bringing humanity back to health ca...

Background Modifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions. Methods We used data on the distribution of exposure to 12 major behavioral and biometric risk factors inthe US population, mortality rat...

To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care. The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making. An interdisciplinary team of improvement experts developed the Change Process a...

Patient-reported outcomes (PROs) can show how patients perceive their illness burden over time. Active use of PROs by clinicians at the point of service can help illuminate the patients' longitudinal changes in outcomes, thereby advancing shared decision making, patient engagement, and self-care. This article offers principles and lessons learned f...

Patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient’s perspective. We use two examples to show how the use of PROMs in everyday practice has the potential to narrow the gap between the clinician...

Background: The Spine Patient Outcomes Research Trial aimed to determine the comparative effectiveness of surgical care versus nonoperative care by measuring longitudinal values: outcomes, satisfaction, and costs. Methods: This paper aims to summarize available evidence from the Spine Patient Outcomes Research Trial by addressing 2 important que...

BACKGROUND Bringing new therapies to patients with rare diseases depends in part on optimizing clinical trial conduct through efficient study start-up processes and rapid enrollment. Suboptimal execution of clinical trials in academic medical centers not only results in high cost to institutions and sponsors, but also delays the availability of ne...

Current methods for tracking harm either require costly full manual chart review (FMCR) or rely on proxy methods that have questionable accuracy. We propose an administrative measure of harm detection that uses electronically captured data. Determine the level of agreement on harm event occurrence when harm is detected based on an administrative ha...

Remarkable biomedical research advances have led to innovative and increasingly effective therapies. We highlight several scientific milestones in elucidating the pathophysiology of cystic fibrosis (CF) and review the therapies that have become available over the past 20 years. In 2002, the CF Foundation launched a multifaceted quality improvement...

Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques....

Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stake...

AimTo investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives. Background Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvem...

Background: Modifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions. Methods: We used data on the distribution of exposure to 12 major behavioral and biometric risk factors inthe US population, mortality...

The Institute for Health Metrics and Evaluation (IHME) developed a risk model to estimate 10-year mortality risk compared with a population with optimum risk factors in adults aged 30 years and older. IHME used data on exposure distributions of 12 behavioural and biometric risks in the US population, mortality rates by cause, and estimates of the p...

Objective: The purpose of this study was to develop a cystic fibrosis (CF)-specific patient and family experience of care survey that CF care centers could use to inform quality improvement efforts. Methods: A literature search and query of CF care centers was conducted to identify existing surveys. Individuals with CF, their families, and healt...

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and...

Context: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? Methods: U...

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to...

With the phrase "the medium is the message", Marshall McLuhan argued that technologies are the messages themselves and not just the medium. Almost 50 years later, we understand that modern information and communication technologies expand our ability to perceive our world to an extent that would be impossible without the medium. In this article, we...

This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI. Background CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged...

The objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare through collaborative learning. The improvement efforts are guided by a systematic approach, combining professional and improvement knowledge. To explore what the i...

Healthcare costs are unsustainable. The authors propose a solution to control costs without rationing (deliberate withholding of effective care) or payment reductions to doctors and hospitals. Three physician-led strategies comprise this solution: reduce (1) overuse of health services, (2) preventable complications and (3) waste within healthcare p...

To improve patient safety, healthcare facilities are focussing on reducing patient harm. Automated harm-detection methods using information technology show promise for efficiently measuring harm. However, there have been few systematic reviews of their effectiveness. To perform a systematic literature review to identify, describe and evaluate effec...

U.S. health care is broken. Although other industries have transformed themselves using tools such as standardization of value-generating processes, performance measurement, and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of “cookbook medicine,” loss of professional autonomy, a mis...

This is a study of 2 clinical feed forward systems (FFSs) situated in different contexts: in the United States, where the system was developed, and in Swedish clinical settings, where it was first adopted. Both systems were identified as clinically successful despite differing contexts, and the objective of this study is to understand what essentia...

Background: In 2005, the Geisinger Health System (Danville, Pennsylvania) developed ProvenCare, first applied to coronary artery bypass graft (CABG), as an innovative provider-driven quality improvement program to promote reliable delivery of evidence-based best practices. A new mesosystem is created for each ProvenCare model, integrating the care...

Background: Two hospitals-a large, urban academic medical center and a rural, community hospital-have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context. CINCINNATI CHILDREN'S HOSPITAL ME...

Background: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small,...

Background: Wherever, however, and whenever health care is delivered-no matter the setting or population of patients-the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to th...

Purpose Our purpose is to describe how coaches who are clinical faculty help in the developmental process of residents to become better physicians and to lead the improvement of quality and safety in the Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR).Methods Using a semi-structured interview guide, eight coaches were...

... microsystems , which comprise a unified health system. EMT, emergency medical technician; Cath, catheterization; Rehab, rehabilitation. Dan Vitale's Acute Myocardial Infarction (AMI) Journey in Health Care Copyright 2008 Joint Commission on Accreditation of Healthcare ...

Unlabelled: BACKGROUND, OBJECTIVES AND METHOD: The Malcolm Baldrige National Quality Award (MBNQA) provides a set of criteria for organisational quality assessment and improvement that has been used by thousands of business, healthcare and educational organisations for more than a decade. The criteria can be used as a tool for self-evaluation, and...

Background: Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measu...

To identify and synthesize characteristics of successful data-driven Quality improvement learning collaboratives (QILCs) in the United States and Europe, and to extend previously discussed and newly identified guidelines for developing successful data-driven QILCs across health care settings and systems. An interview guide of open-ended questions w...

The purpose of this study was to determine how many patients are needed to provide reliable patient ratings of care at the individual clinician level. SETTING AND SOURCES OF DATA: The study was conducted in an academic medical center and was based on analysis of 34,985 patients who completed a 50-item survey rating the care received during a recent...

Purpose: To provide guidance on using measurement to support the conduct of local quality improvement projects that will strengthen the evaluation of results and increase their potential for publication. Target group: Individuals leading quality improvement efforts who wish to enhance their use of measurement. Procedures to promote good measure...

Plan-do-study-act (PDSA) quality improvement is the application of the scientific method to implement and test the effects of change ideas on the performance of the health care system. Users of quality improvement could benefit with markers to gauge the "best" science. Four core questions can determine the value of a quality improvement study: Is t...

This last Microsystems in Health Care series article focuses on what it takes, in the short term and long term, for clinical microsystems--the small, functional, front-line units that provide the most health care to the most people--to attain peak performance. A case study featuring the intensive care nursery at Dartmouth-Hitchcock Medical Center i...

The articles in the Microsystems in Health Care series have focused on the success characteristics of high-performing clinical microsystems. Realization is growing about the importance of attracting, selecting, developing, and engaging staff. By optimizing the work of all staff members and by promoting a culture where everyone matters, the microsys...

This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navig...

Background: Leading and leadership by formal and informal leaders goes on at all levels of microsystems--the essential building blocks of all health systems--and between them. It goes on between microsystems and other levels of the systems in health care. This series on high-performing clinical microsystems is based on interviews and site visits t...

Despite many patients undergoing coronary artery bypass grafting (CABG) to improve their functional status, literature in this area is limited. The purpose of this study is to determine the effect of CABG on the functional health of an elective population and to identify preoperative patient characteristics associated with improved functional healt...

Background: Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient's ability for self-management, is an essential result of a productive i...

Background: Strategic focus on the clinical microsystems--the small, functional, frontline units that provide most health care to most people--is essential to designing the most efficient, population-based services. The starting place for designing or redesigning of clinical microsystems is to evaluate the four P's: the patient subpopulations that...

A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care. At The Spine Center at Dartmouth, Lebano...

Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the servi...

The authors show how an internal grant program can stimulate quality improvement research by providing technical and financial support to clinicians and employees.

The authors describe their study of 20 high-performing clinical units and discuss its practical implications for leaders seeking to improve performance.