Table 3.

Participant Quotes Related to Learning Principles of Learning Health Systems

Learning Principle	Corresponding Show-Me ECHO Participant Comments
Draw on wisdom of groups and value connections	There is a huge need for pediatric providers in rural settings to be better educated in identifying characteristic and to be able to screen in order to initiate therapies early. I participate because it is a support resource, links me to the professional who educate and guide me in the care of my patients. Learning from other professionals that I usually would not be able to connect with on a regular basis. There was a need for better care in my area and this was a great opportunity to connect with specialists and other providers to help provide that care.
Embrace sense-making over decision making in dealing with the unexpected	When a case was presented and then talked out with everyone’s ideas, I found that it helped me be more open minded. Case presentation review - I think I understand something till we talk about it in a particular patient scenario. The opportunity to get expert help is immeasurably important. Another way to connect to the asthma community to share ideas and troubleshoot difficult cases.
Bring diverse perspectives to complex challenges	To observe other CHWs styles or approaches to difficult cases. It is reassuring knowing others in this position may have the same struggles. Also, one can learn about resources they might not be aware of. I have a better understanding of the legal implications involving guardians, the legal system, and the medical field. Learn from other clinicians how they are working though hurdles of accessing and managing HCV treatment for their specific patient populations.
Animate people, provide direction, update regularly, and Interact respectfully	The collegial atmosphere is very conducive to learning without feeling threatened or left out. There are no stupid questions and we don’t have egos in this group. We help each other learn. Feels like a true team.
Appreciate the power and ubiquity of emergent change and the limitations of planned change	Made aware that there are occasions that seem to be the right thing to do may be in conflict with regulations. I enjoyed finding new resources and helping other CHWs that may have run out of ideas for helping a patient. Saw a need in my patients and those in my community-long wait times at specialty centers.
Concentrate on small wins and characterize challenges as mere problems	Passion to make a change in a rural health setting to offer a broader developmental screen to catch these children early for earlier intervention to improve the overall outcome. Brainstorming ideas with fellow peers regarding resources and patient care. The wait for referral to [Autism] Center was so long for my patients that I was excited to be able to facilitate quicker access to treatment for children in rural areas. Saw a need in my patients and those in my community-long wait times at specialty centers

^*Representative quotes come from participants of the following ECHOs: Asthma, Autism, CHW, Derm, Ethics, Hep C, HIV, OUD, Pain.