Table 2 Summary of challenges and potential solutions identified by the included learning health systems

Data

 Lack of standardized data or data that is low quality or missing [46, 55].

Use of a ‘mediation’ approach to data interoperability (i.e. standardization) allows for different EHR vendors to be linked, saves time and money from reorganizing the whole network, allows new data to easily be incorporated, and for flexibility with how the data is used [63].

Adapting interventions to fit existing EHRs to ease dissemination of findings [30].

Standardization of data and processes across systems [13].

 Lag in updated data including patient lists [15].

Real-time access to and analysis of data [17, 20, 40, 70].

 Need to access data without the assistance of a data analyst [21].

Use of LHS tools / dashboards with minimal or no training (i.e. ease of use by all providers) [67, 80].

 Patients who do not get all their care through one system / organization or out of pocket expenses not covered, so complete data is not captured [15, 27, 45, 70].

Universal healthcare coverage for some regions including Switzerland and the United Kingdom [53, 59].

Organizational factors

 Uncertainty of financial sustainability [18, 22]

Internal drivers and resources within the organization, rather than depending on external funding [13, 53, 57, 73].

 Increasing awareness of LHS and developing a culture of learning and improving throughout organization [21].

Broad adoption of programs across leadership and providers [24, 35].

Embedding researchers within the healthcare system [13].

Training highly qualified personnel and educating healthcare providers to support a sustainable culture for learning and encouraging participation in learning / quality improvement activities [16, 17, 34, 40].

 Need to involve patients and community [20, 21, 31, 34].

Initiatives to increase patient and family involvement, including the development of patient and family advisory councils, or allowing patients to access their data through secure patient portals [20].

 Need to reduce practice variation across different sites [24, 44].

Use of better tools to reduce practice variability, including strategies to engage and help low-performing practices [44].

 Need to develop processes to assist in prioritizing learning across the organization [20].

Priority setting within the organization to identify high-impact projects and initiatives, including the development of a committee to review and approve proposals [16, 17, 39, 40].

Research / quality improvement

 Need to make current EHR systems work better for research or quality improvement / how to deal with the extra time required by providers to participate [30, 46].

Incorporating data collection for research or quality improvement into clinical care rather than it being extra work for providers or staff [46, 51].

 Need for quality improvement activities rather than traditional research to allow for more efficient analyses that can be easily incorporated into practice [44, 70].

Different initiatives to support quality improvement across the organization. For example:

○Holding annual quality improvement conferences where project leaders can share their experiences, which are then collated to provide a library of quality improvement initiatives [16].

○A whiteboard in each clinic that lists all system-wide and clinic-specific quality improvement initiatives currently in progress at that location [17].