September 18, 2017

A core competency for health system researchers: Striking a balance


Researchers working with clinical partners on health system improvements can learn from yoga principles, writes Sarah Greene

by Sarah Greene, MPH, executive director of the Health Care Systems Research Network, previous Kaiser Permanente Washington Health Research Institute faculty member, and yoga-instructor-in-training

Momentum for the learning health system (LHS) model is steadily building. In an LHS, research influences clinical practice and practice influences research. Forward-thinking delivery systems like Kaiser Permanente, Geisinger Research and Health System, and others in the Health Care Systems Research Network (HCSRN) recognize the value of leveraging vast stores of electronic data and bringing research and care delivery closer in support of more agile, patient-focused, evidence-driven practice. Moreover, insurers are focusing on creating value using the best available evidence, given the intensifying focus on drug costs, high health care utilization, and variations in care.

For my work leading the HCSRN, a national collaborative network of health system research organizations, and for my yoga practice, of late I’ve immersed myself in two different categories of reading material. On their face, they seem disconnected: recent literature on the LHS, and a series of books on yoga philosophy. But in reading the excellent new piece from Chris Forrest and colleagues on training LHS-embedded researchers, I’m struck by the overlap between embedded research and two key pillars of yogic teaching.

How research is like yoga

Many distinguished yoga teachers (I suppose you can call them gurus) distinguish between “over-efforting,” or forcing, and “under-efforting,” or being complacent. As researchers, we can’t be complacent when collaborating with clinic chiefs, IT directors, and other operational leaders. Since we can’t assume they share our research concerns, timelines, or language, we have to make the effort to work with them to find shared objectives. But we can’t force collaborations with delivery system leaders with studies that benefit our research more than their improvement goals.

We have to find the right balance, and make adjustments by tuning into the present context. Think about the cycle we experience as researchers: characterized by periods of urgency (write a grant by the deadline) and dormancy (wait for the grant reviews).

But as we partner with our health systems on studies conducted in their workplaces, we must remember that we are merging our research into their existing slipstream. Their context is very present-focused: this patient, this visit, this diagnosis, this treatment. Hence, we have to find the right balance between too much effort, brute-forcing our study into the clinic workflow, and too little, assuming agreement that might not exist. We have to find ease — thoughtfully exploring how existing clinical operations can support our study, bringing the novel input of physicians and clinical staff to bear on research methods we’ve been using and reusing for years.

Another way the LHS reminds me of yoga is through the concepts of karma and samskara. Yoga teaches us that karma is any action or intent, and samskara is the patterning that imprints itself after an action. We develop tendencies and subtle traits based on past actions that repeat themselves in new actions. Whether positive or negative, the point is we form habits that might be difficult to undo.

The LHS, as a new paradigm, demands that we create new ways of conceiving questions and collaborations. We need to reach beyond our usual patterns and imprints to take in information that might lead us to embark on different methods and research questions, rather than doing what we’ve always done.

We may even need to re-think our thresholds about “significant” data, as the Forrest paper points out: “For health systems, research evidence may not need to meet the same standards as medical evidence for clinical decision making; often good enough evidence is sufficient to make strategic, operational, or financial decisions. Balancing the desire of health systems for rapidly generated, practical evidence with the rigors of peer-review and scientific standards is one of the key challenges for LHS researchers.” We may need to step out of the comfort zone created by the statistical threshold of p <0.05.

It’s a journey

Forrest et al. suggest LHS researchers train in core competency domains where Kaiser Permanente Washington Health Research Institute and HCSRN researchers have strengths — areas such as stakeholder engagement, data informatics, and embedded research methods. This is a wonderful next step as we continue to realize this paradigm shift at the junction of medicine and research.

However, this plan is not a quick fix or magic wand. It will take time, lived experience, and cohorts of trainees working with experienced health system-based researchers and clinical partners. To realize our goals, some future work might include:

  • Determining the right venue for training, and the balance between didactic and experiential learning. For instance, one of the domains is improvement and implementation science. These related fields are guided by theoretical frameworks and methods that can be taught pedagogically. However, successfully applying these methods depends on exposure to and experience in a health system itself.
  • Discovering whether a temperament or interpersonal orientation is associated with LHS research success. Currently, research can be relatively solitary. But the early experience of many of us working in an LHS shows that multidisciplinary collaboration with new kinds of teams is essential.

We must also realize that the growing emphasis on moving research results quickly into practice means our next generation of studies might not follow the traditional grant timeline. We might move immediately to address urgent clinical priorities surfaced in discussions with a regional medical director. In that case, we must figure out how to simultaneously ensure rigor, expediency, and rapid funding.

The LHS training framework from Forrest and colleagues illuminates how far we have to go as we integrate our more conventional research approaches into a dynamic and evolving health care environment. Just as yoga is considered a “practice” that we learn and hone over time rather than an endeavor with a finish line, achieving an LHS is also something we need to learn through sustained practice.


Learn more about the Kaiser Permanente Washington LHS initiative from Vice President for Research and Health Care Innovation Dr. Eric B. Larson. Visit the Kaiser Permanente Washington Health Research Institute website. Sign up for our free monthly newsletter.