Physicians deliver about half of indicated care, and patients do about half of what it takes to stay healthy, despite the best intentions and tireless efforts of both physicians and patients. The learning healthcare system (LHS) has been proposed as a solution. As envisioned by the Institute of Medicine, an LHS would “generate and apply the best evidence for the collaborative health-care choices of each patient and provider, drive the process of discovery as a natural outgrowth of patient care, and ensure innovation, quality, safety, and value in healthcare.”1(p354) But this model begs the question: Who is learning? And how? Traditional models suppose that highly trained experts—expert clinicians and expert researchers—are best suited for producing information, knowledge, and know-how. This reliance, however, on a small group of experts to improve health care and health outcomes has yielded the current system performance and impedes immediate, continuous, and trans-formative improvement. A new model of production is necessary.
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