New clinical research paradigm: drawing clinical research closer to the experience of clinical practice, including the development of new study methodologies adapted to the practice environment and a better understanding of when RCTs are most practical and desirable.

Clinical decision support systems: to accommodate the reality that although professional judgment will always be vital to shaping care, the amount of information required for any given decision is moving beyond unassisted human capacity.

Universal electronic health records: comprehensive deployment and effective application of the full capabilities available in EHRs as an essential prerequisite for the evolution of the learning healthcare system.

Tools for database linkage, mining, and use: advancing the potential for structured, large databases as new sources of evidence, including issues in fostering interoperable platforms and in developing new means of ongoing searching of those databases for patterns and clinical insights.

Notion of clinical data as a public good: advancement of the notion of the use of clinical data as a central common resource for advancing knowledge and evidence for effective care—including directly addressing current challenges related to the treatment of data as a proprietary good and interpretations of the Health Insurance Portability and Accountability Act (HIPAA) and other patient privacy issues that currently present barriers to knowledge development.

Incentives aligned for practice-based evidence: encouraging the development and use of evidence by drawing research and practice closer together, and developing the patient records and interoperable platforms necessary to foster more rapid learning and improve care.

Public engagement: improved communication about the nature of evidence and its development, and the active roles of both patients and healthcare professionals in evidence development and dissemination.

Trusted scientific broker: an agent or entity with the public and scientific confidence to provide guidance, shape priorities, and foster the shift in the clinical research paradigm.

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