Knowledge Management in a Learning Health System

Introduction

Over the past few centuries, medical science has been growing steadily. The pace has accelerated in the last few decades. This new knowledge is slow to change the practice of medicine, although we have been using information technology tools for data collection, manipulation and analysis. Sample sizes have grown bigger over the years for clinical trials. Today, with the implementation of electronic health record (EHR), availability of clinical data has increased. It is now possible to study the whole population instead of a sample using machine learning and artificial intelligence tools. The speed and capacity to manipulate and analyze data have increased tremendously with the availability of larger capacity of hardware, faster software and better algorithms. We are about to see a flurry of new discoveries and new knowledge. This chapter will discuss the role of (i) knowledge curation, (ii) knowledge translation and (iii) new knowledge generation in medicine using machine learning and artificial intelligence in a learning health system.

History

Medical knowledge includes an understanding of all established and evolving biomedical, clinical, epidemiological and social-behavioral sciences (NEJM, 2016). The process of creating medical knowledge started with the observation of humans many centuries ago. One would observe the normal state and the diseased state. This exploration leads to the examination of the human body both outside and inside, through dissection of cadavers and sometimes operating on living humans. The modern science of observation and measurement did not start until the early 1600s. The observation of hygiene and its effect on the mortality of wounded soldiers, the incidence of cholera in a certain geographic area in London and the incidence of lung cancer in cigarette smokers are all great examples of how observational science started making its way into medical practice. The traditional use of clinical trials in medical treatment became popular with the birth of the pharmaceutical industry in the late 1800s. The study of populations and statistics became popular as tools in science and medicine in the late 19th century.

Current Practice

According to a paper by Peter Densen, there are several challenges facing medical education and medical knowledge today (Densen, 2011):

1. The majority of medical education is focused on biology, but most of the disease is caused by non-biological factors, like behavioral choices and the environment.

• 2. The majority of medical education happens in a hospital setting, while the majority of the practice of medicine happens in the outpatient clinic setting.
• 3. Major emphasis on basic science research, but a lot of it is not very applicable to the medical practice at the bedside.

There is a gap between what medical science has discovered as new knowledge and the access and usability of that knowledge to benefit patients. This is also called the bench-to-bedside gap (Mohyuddin, 2015). There are several barriers to this process of transfer of knowledge. Factors that are contributing to this gap between evidence and practice of medicine are

• 1. The exponential growth of knowledge and the number of studies, with the number of studies doubling every few months (Corish, 2018).
• 2. An increasing population that is also having a growing number of older individuals with heart disease and cancer, which are still the leading causes of death (AHRQ, 2017).
• 3. Increasing amounts of healthcare data from EHRs, imaging studies and genomic information (IDC, 2014).
• 4. Physicians are unable to keep up with evidence-based care, resulting in less than half of the patients receiving it with resulting increased mortality and morbidity (Holmes et al., 2004).

The importance of clinical trials and the scrutiny they get have been enhanced by the modern drug development practices and the rigorous regulatory framework that has been established to protect the people from ineffective or dangerous drugs, devices or treatments getting into the practice of medicine. The invention of new compounds, molecules and biologies has accelerated this process. Some of the challenges faced by the industry like the increasing cost of bringing treatment into the market, the enormous failure rate of these treatments in the clinical trials and sometimes the lacklustre performance of these treatments when they have been disseminated into a population have all been documented. Once studies have confirmed that a treatment works, it is picked up by the professional organizations that will include this evidence into clinical practice guidelines. These guidelines are disseminated widely to the practicing physicians through publications. Physicians and healthcare institutions have to voluntarily include this guideline-based knowledge into their practices. This cost, time and quality inefficiency has been plaguing the medical world for quite some time and more so recently