key: cord-1021149-0c7oaymq
authors: Vinson, Alexandra H.
title: Putting the network to work: Learning networks in rapid response situations
date: 2020-11-11
journal: Learn Health Syst
DOI: 10.1002/lrh2.10251
sha: 2c10ce7d98df2cd65d4b57558a87a9746ea7d87e
doc_id: 1021149
cord_uid: 0c7oaymq

INTRODUCTION: The rapid response to COVID‐19 has necessitated infrastructural development and reorientation in order to safely meet patient care needs. METHODS: A qualitative case study was constructed within a larger ethnographic field study. Document collection and fieldnotes and recordings from nonparticipant observation of network activities were compiled and chronologically ordered to chart the network's response to changes in epilepsy care resulting from COVID‐19 and the rapid transition to telemedicine. RESULTS: The network's response to COVID‐19 was characterized by a predisposition to action, the role of sharing as both a group practice and shared value, and the identification of improvement science as the primary contribution of the group within the larger epilepsy community's response to COVID‐19. The findings are interpreted as an example of how group culture can shape action via a transparent and mundane shared infrastructure. CONCLUSIONS: The case of one multi‐stakeholder epilepsy Learning Network provides an example of the use of infrastructure that is shaped by the group's culture. These findings contribute to the development of a social theory of infrastructure within Learning Health Systems.

In March, 2020 coronavirus disease 2019 (COVID-19) began to affect major population centers in the United States. Immediately, healthcare organizations began to respond with a rapid switch to telemedicine. 1 In their adaptation, healthcare providers faced a number of challenges, including disparities in patients' access to smartphones and computers to participate in telemedicine care, the management of information and knowledge in an uncertain environment, and the management of complex human factors that surrounded the pandemic, such as provider morale, anxiety, and access to personal protective equipment.

While some healthcare systems may have had to create new infrastructures for coordinating their response to COVID-19, others may have been able to use an existing infrastructure to coordinate action. 2, 3 In either case, disasters like pandemics have the ability to lay things bare: "As societies respond to these challenges, features that we have taken for granted suddenly become transparent. For a moment, our own world can become anthropologically strange" (Dingwall et al, 4 p. 167).

Infrastructure studies, a prominent subfield within Science and Technology Studies (STS), takes analytic advantage of moments where the taken-for-granted features of everyday life become apparent. 5 The idea that infrastructures are invisible under normal circumstances is fundamental to this field. 6, 7 Noticing infrastructures happens most commonly when those infrastructures break down, but, as in the case of the COVID-19 pandemic, infrastructures can also become visible when everything else breaks down around them.

In this article, I present a case of how the members of one Learning Health System reoriented their work to respond to the effects of the COVID-19 pandemic on their network members. In doing so, I argue that this case broadens our understanding of the infrastructural aspects of Learning Health Systems (LHS). One of the central issues in the field of LHS is how to develop the infrastructures that support the work of the LHS. 8 When issues of infrastructure are raised, what is most often discussed is the information infrastructure that underpins the data-gathering and aggregation that enable the continuous improvement work of the LHS. 8 But these are not the only properties and actions of infrastructures.

Existing research on Learning Networks, one form of LHS, emphasizes the role of people and community-in addition to other elements of infrastructure-in doing the work of the LHS. Past work has emphasized that Learning Networks have an actor-oriented architecture, which "consists of actors (people and institutions) with the values and capabilities to self-organize; a commons where they create and share resources; and structures, protocols, and processes that make it easy to form highly functional teams" (Seid et al, 9 p. 2) . There is also a shared infrastructure across networks that can be customized to individual networks' needs. 9 Thus, there are some standardized elements of infrastructure, but also a recognition that infrastructure needs to be adapted for the particular needs of a given network.

Researchers in this field have called for "detailed studies of the mechanisms by which learning networks lead to improved results" (Britto et al, 10 p. 944).

The work presented here adresses that call: I examine the social elements of Learning Network activity, producing theoretically informed explanations of how Learning Networks accomplish their work. Similar to Collier (2011, as described in Larkin 11 ), my interest in infrastructure is not simply in the ways that infrastructures make themselves known in the world. Rather, I turn my focus to "practices of conceptualization that come before the construction of the systems themselves and which are engineered into them […] Infrastructures become the material evidence of this transfer" (Larkin, 11 p. 332).

As part of this work, I examine how a group's culture is made material in and through a group's infrastructure.

How and why should we study infrastructures? In STS, studying infrastructures is often described as studying the mundane. In fact, Leigh Star 6 has famously written that infrastructure is "frequently mundane to the point of boredom" (p. 377). This humorous phrasing draws one into a reorientation of topics that are taken to be boring, showing that they contain phenomena of great interest to scholars of infrastructure: how human activity becomes coordinated, how information is shared among group members, and how groups cope with infrastructural breakdown.

Infrastructures have a variety of properties. Relevant for the present case are that infrastructures do not have to be built anew for each process, and infrastructures generally support ongoing activity in ways that are invisible to the user. 7 Furthermore, infrastructures are inhabited by members who know how the infrastructure works and how to use it. 6 Members within infrastructures do ongoing work to connect different infrastructures and to work across them. 12 And, finally, infrastructures become visible when they break down. 6 While many cases in the literature examine infrastructural break- In keeping with the tradition of interpretive ethnography, which uses long-term engagement with a group to learn about group culture and practices, this analysis seeks to describe how the culture of a group shapes the group's course of action. 13 While culture does not determine thought or action, one effect of culture is that it makes some courses of action seem more logical than others. In this case, I examine how different elements of ELHS's culture, namely shared values and practices, shaped their course of action during the COVID-19 response, such that certain courses of action seemed logical.

For this analysis, I constructed a case study within the ongoing qualitative field study described above in order to examine how ELHS 

The data sources identified above were compiled, transcribed where necessary, and chronologically ordered. This arrangement of data had 

The protocol for this research study was reviewed by the University of Michigan IRBMED (HUM00148389) and determined to be exempt and not regulated.

The transition to telemedicine involved the rapid creation of new infrastructures in healthcare systems around the world. However, not all infrastructures had to be developed de novo. As I describe, organizations like ELHS were able to repurpose elements of their infrastructure to support network sites in making the transition to telemedicine.

The ability to address a novel problem with a pre-existing infrastructure is a hallmark of a learning health system, and to see it in motion, as I show here, is to see how the network infrastructure can be put limited ability to participate in network activities like clinical data collection was not a problem.

For those who could continue to participate in network activities, monthly all-network calls took on a crowd-sourcing role. A request for input and sharing was circulated that asked sites to share input on:

"How COVID-19 is impacting your practice/team," "What work for ELHS seems doable from your perspective in the near future," "Any recommendations/shared best practices or questions on the above items or other," and "Any successes/barriers you can share from your recent ELHS work in practice." These questions oriented participating sites toward sharing information with other sites and with the Leadership Team. After this all-network call, the notes and call recording were shared with all network members so that sites could learn from each other's successes and challenges asynchronously.

In addition, the newsletter, a second information-sharing element of the network infrastructure, was repurposed as a mechanism to share COVID-related information with network members. 

As changes to network events were put into place, ELHS leadership discussed how best to respond as a network to patient care and patient self-management concerns that were arising within the epilepsy community. Certain considerations emerged as semantic themes 14 : the importance of only using network members' limited time for content that was relevant to responding to COVID-19, as well as the role of ELHS in helping patients and providers cope with disparities in access to telemedicine technology. There was also an awareness that one benefit of being in a networked system was that 

The notion that network members share their challenges and successes and that the leadership team use the network infrastructure to aggregate and further share this information was a practice and value that characterized ELHS's work. This could be observed in the expectations for sharing that ELHS leadership set for network members who would be attending the March all-network call:

What team successes can you share so we can celebrate? What team barriers are you working to overcome? Another team may be dealing with the same barrier and we learn so much through sharing.

In this instance, sharing is presented as a conventional practice of the group that leads to the network's learning. In addition to being a practice, sharing is also a value that is reinforced during ELHS allnetwork activities and communications:

We were thrilled to hear so many teams share 

Another feature of the ELHS COVID-19 response was that network leaders were predisposed to act, and moreover, that they accepted acting as a network to respond to COVID-19 as a matter of course.

This predisposition toward action was linked closely to ELHS leadership's sense of their network's purpose. For example:

Because I field probably 30 or 40 questions a day of, "what's the data on this?" You know, "how do we approach that?" You know, "what's best practice for this?" And we don't have any of those answers, but I think we can have those answers, or at least preliminary answers, on a lot of those issues very, very quickly.

We can do that. We need to start doing that. And then we need to disseminate not just to our members, but in this setting of crisis, we need to show that this way of working is the way to work. [Emphasis added]

Here, one network leader forcefully articulated the potential role of ELHS in the COVID-19 response: ELHS was uniquely able to get answers about best practices for epilepsy care during the pandemic. This leader extended her vision to argue that the findings needed to be shared ("And then we need to disseminate…") and that a case needed to be made that ELHS's way of working was "the way to work" in a setting of crisis. As I discuss in the following section, the way of working that this leader had in mind was to use principles of improvement science, namely plan-do-study-act testing, taking the practice guidelines being developed by epilepsy professional associations and testing them in actual clinic settings to see what worked.

The novel challenges presented by COVID-19 made it difficult to know how to respond. Indeed, as one leader stated during a leadership discussion in March, "nobody has a playbook for this." However, improvement science fundamentally provides a method for producing a playbook, and one ELHS leader was able to convincingly argue that improvement was the logical way for ELHS to contribute in the environment of uncertainty created by COVID-19:

I just see this, you know, we're playing this game of 

Finally, I return briefly to the notion that infrastructures are composed

of mundane yet important elements that help a network do its work.

The infrastructural elements I have described in the sections aboveincluding the newsletter, the monthly all-network calls, the Learning Session, and the collaborative workgroup structure-can be harnessed as neutral vehicles for targeted content. This means that the same infrastructure that has been used to standardize seizure documentation can be used to respond to changes in epilepsy care due to COVID-19. The infrastructural elements of the network enabled the leadership team to share information with the network sites, the network sites to share information with each other, and the network sites to share information with both the network leadership and the many stakeholders who are participating in epilepsy care at network sites. In this way, the network accomplishes its iterative work of testing and sharing discrete interventions into epilepsy care. The case of ELHS has lessons for Learning Health Systems broadly that move the analysis beyond the findings reported above. First, it is important to build an infrastructure before it is needed. If a group has an infrastructure before a crisis hits, the group can use that same infrastructure to help respond to the crisis. Second, ELHS leaders were adamant that ELHS should not duplicate any work that was already being done by another group in the epilepsy community. The lesson here is to identify the contribution a group is best suited to make and to execute on it. For ELHS, this was the application of improvement science techniques to test potential best practices promoted by member sites and national epilepsy organizations. Finally, a third lesson is to not underestimate the mundane elements of infrastructure that are crucial for accomplishing a group's work. Once those elements are known, they can be put to work. This is a strong argument for building infra- 

The author has no conflict of interest to declare.

Alexandra H. Vinson https://orcid.org/0000-0002-9062-7899

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How to cite this article: Vinson AH. Putting the network to work: Learning networks in rapid response situations