No doubt in the future there will be an intensive review of what happened and what we learned from the covid-19 pandemic, but what about right now? Are we employing, in real time, the most efficient and effective learning tools to help today’s clinicians, organizations, and governments as the pandemic unfolds?  In late December 2019, Li Wenliang, a 34-year old ophthalmologist who worked at a hospital in Wuhan, China, noticed a cluster of cases of a flu-like illness that reminded him of the SARS virus that sprang up in China in 2003. [1] In a move that likely saved many health workers lives, he sent a message to fellow clinicians via a group chat, urging them to don protective gear. By the time of his death from covid-19 in early February, the virus had spread to 25 countries. Wenliang’s brave act of rapidly communicating his observations and advice to a network of colleagues using social media presaged a global wave of unprecedented rapid knowledge sharing that may change how we think about learning in the future.

As traditional knowledge management systems—a time-consuming process of dissemination in journals or conferences—ground to a halt, methods for widely distributed, fast-paced, real-time learning and dissemination more suited to a pandemic response have become dominant. Clinical trials are being conducted, reviewed and disseminated over days and weeks with a resulting explosion of new knowledge; over 9000 peer-reviewed papers were published on covid-19 in the last four months. [2,3] An unprecedented increase in non-peer-reviewed publications has fast-tracked promising new ideas and treatments, but also raised concerns about information quality. [4] Clinical communities, especially those most affected, used open-source methods to access the wisdom of their colleagues across countries and continents, learning from each other and updating guidelines.  

Some countries in which the epidemic curve is lagging by even a month or two are already harvesting lessons and applying them quickly. African countries have swiftly closed borders and restricted movement, buying time to stock up on supplies, get infrastructure in place and better prepare staff for the expected surge in hospital admissions in the months ahead. In the US, the Institute for Healthcare Improvement’s Leadership Alliance—a learning network of 55 healthcare systems—very early on began to trade operational and clinical insights in discussions that were facilitated by existing trusted relationships within the network. Within minutes of posting a query, people in the network could respond with their approach to the issue at hand.  Where evidence isn’t present, group process sets the prevailing norms and standards. At Addenbrookes Hospital, UK, teams are condensing into days a process for developing standard operating processes that that typically takes months. [5] In response to ongoing amendments of national guidance, teams are quickly mapping safe workflows, formulating new designs, iterating on those new designs through rapid frontline testing, and then deploying new effective standard processes across the system. These nimble approaches are enabled by leaders who value and promote frontline learning about the relative effectiveness of non-pharmacologic, operational, and public health interventions for the covid-19 response. 

Modern information technology tools are enabling these rapid learning systems, including webinars delivered to thousands on video platforms like Zoom and Webex, collaboration channels like Slack, dissemination platforms like Twitter and Facebook, and asynchronous conversation platforms like traditional listservs and WhatsApp groups.  These social networking mechanisms are extremely helpful in rapidly disseminating new information to a large audience, but they may not be sufficient to understand how to implement this information. The best ideas about implementation coming from the frontlines of care may need more effective channels, not just for their expression and sharing, but for synthesis, dissemination and testing of these ideas. 

We predict that systems that learn fast with enabling leadership will emerge from this stage of the pandemic sooner, stronger and better prepared for what comes next. Countries and health systems that are effectively responding to the epidemic are using a broad array of rapid learning methods and tools. Learning mechanisms are being built into hospital designs, new learning roles have emerged and leaders are showing flexibility and courage to allow local adaptations to occur at the frontlines in real time. In addition to the flurry of large scale sharing of new knowledge through organized virtual meetings and more organic community forums, we should be developing even more inclusive health system community designs. Borrowing from social media formats, we can provide well-curated community forums where learnings can be rapidly surfaced, harvested, vetted, and disseminated both back to the frontline for improving care processes and “up” to decision makers to produce better implementation designs.  

The concept of “learning health systems” has never more relevant. [6] We are seeing one of the world’s most productive periods for implementation science—putting practical knowledge about both what and how to implement the covid-19 response into the hands of practitioners, managers and policymakers. Amid the tragedy, the covid-19 epidemic will also leave us with new ways of learning—quickly and efficiently—that may forever change the way we discover and deliver better care in the future.  

Pierre Barker, Chief Global Programs and Partnerships Officer, Institute for Healthcare Improvement, Boston MA

Kedar Mate, CEO and President, Institute for Healthcare Improvement, Boston MA

Don Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, Boston MA

Competing Interests: none declared

References:

1. Li Wenliang. https://en.wikipedia.org/wiki/Li_Wenliang. Downloaded 05/07/2020
2. Jarvis C. Journals, Peer Reviewers Cope with Surge in COVID-19 Publications. New Scientist. March 2020 https://www.the-scientist.com/news-opinion/journals-peer-reviewers-cope-with-surge-in-covid-19-publications-67279
3. https://www.ncbi.nlm.nih.gov/pubmed/?term=covid-19 downloaded 05/07/2020
4. Debes JD, COVID-19 and the liver: the perils of non-peer reviewed science in times of a pandemic, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2020.04.007.
5. Dr F Gilder personal communication 
6. The Learning Healthcare System. Workshop Summary. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Eds: Olsen LA,  Aisner D, and McGinnis JM. Washington (DC): National Academies Press (US); 2007