Table 1.

Key Elements of an LHS

Key elements	Description
Patient and family engagement	An LHS recognizes and engages patients and families as active partners in the processes of learning. Strategies to engage patients and families may include the establishment of a Patient and Family Advisory Council as implemented by the Geisinger Health System (Psek et al., 2015).
Multistakeholder collaboration	An LHS is participatory and involves key stakeholders early in its design to ensure that their ideas are represented and their needs are met. A diverse set of internal and external stakeholders should be engaged, and innovative partnerships may need to be developed. Stakeholders include, but are not limited to, patients, families, relevant interest groups, identifiable communities, scientists, practitioners, staff members, and leaders in clinical, administrative, research, and data analytics areas. A nationwide LHS should engage federal agencies and public health agencies among other entities (Bernstein et al., 2015; Friedman et al., 2010).
Transparency and accountability	An LHS is open, transparent, and accountable in its operation to foster trust of all stakeholders. There is a need to rethink the traditional distinction made between clinical care and research and develop an ethics framework more suited to the priorities and needs of an LHS (Psek et al., 2015).
Adaptability	An LHS enables iterative learning and rapid adaptation to meet current and evolving healthcare needs. Scientific rigor lies at the core of an LHS to ensure the validity and credibility of research findings and their application, although there may be a need to consider and develop mechanisms to balance the potential trade-off between speed (rapidity) and accuracy (Friedman et al., 2015).
Leadership support	LHS activities should be aligned with strategic and operational goals. Senior health leaders are more willing to support an LHS model and its activities when they are aligned with existing strategic and operational goals (Psek et al., 2016). Consideration should be given to the potential tension between transformation and supporting existing strategic plans.
	Leadership support can help promote an organizational culture that embraces learning and bridge relationships across disciplinary teams, which often operate in silos. Leadership can also establish performance criteria and provide incentives and working conditions for learning activities; front-line services may be best positioned to identify gaps in healthcare and drive learning at the operational level (Psek et al., 2015).
Sustainability	An LHS is based on a sound business and governance model with strategies to enhance and sustain funding of learning activities. Financial and nonfinancial incentives should be provided to promote learning activities, particularly in clinical settings. Although an LHS is set up to improve care and lower costs, its implementation will require financial investment initially (e.g., technical and operational costs) and may compete with other organizational priorities for limited resources. (Friedman et al., 2015; Psek et al., 2015, 2016)
Data and analytics	IT infrastructure is needed to capture data at the point of care and allow for real-time assessment and knowledge generation. There should be a mechanism to protect security, privacy, and confidentiality of data and information (Psek et al., 2015).
Timely evaluation and dissemination	An LHS has the capacity to engender a continuous cycle of learning and improvement. Evaluation should be pragmatic, flexible, transparent, scalable, and timely, and should not create unnecessary or additional burdens on clinical operations or patient well-being (Psek et al., 2015). The processes of operationalizing an LHS and the performance of an LHS need to be distinguished. There may be a need to explore innovative evaluation methodologies and provide training opportunities in them. There should also be effective communication channels for timely dissemination and open discussion of research and evaluation findings with internal and external stakeholders (Greene et al., 2012; Psek et al., 2015).

LHS, learning healthcare system.