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Background: Collaborative learning health systems (CLHSs) enable patients, clinicians, researchers, and others to collaborate at scale to improve outcomes and generate new knowledge. An organizational framework to facilitate this collaboration is the actor-oriented architecture, composed of (a) actors (people, organizations, and databases) with the values and abilities to self-organize; (b) a commons where they create and share resources; and (c) structures, protocols, and processes that facilitate multiactor collaboration. CLHSs may implement a variety of changes to strengthen the actor-oriented architecture and enable more actors to create and share resources.Objective: To describe and measure implementation of elements of the actororiented architecture in an existing Collaborative Learning Health System. Methods:We used the case of ImproveCareNow, a CLHS improving outcomes in pediatric inflammatory bowel disease, founded in 2006. We traced several networklevel indicators of actor-oriented architecture between 2010 and 2016. Results:We identified measures of actors, the commons, and ways that have made it easier for network member sites to participate. These indicators show ImproveCareNow has made changes in the three elements of the actor-oriented architecture over time. Conclusion:It is possible to measure the implementation of an actor-oriented architecture in a CLHS. The elements of the actor-oriented architecture may provide a conceptual framework for their development and optimization. Metrics such as those described here may be actionable indicators of the "health of the system." K E Y W O R D Schronic care, collaborative learning health systems, organizational theory

Most of these very ill patients did readily discuss these sensitive issues with the research nurse. Cardiovascular training in end-of-life care should include sensitivity to ethnic and cultural preferences and competencies in interviewing on sensitive topics.

Background Learning Networks are distributed learning health systems that enable collaboration at scale to improve health and health care. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. Objective We describe a Learning Exchange—a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network—and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. Methods Acceptability was assessed via growth in active users and activity. Feasibility was measured in terms of the percentage of users with a log-in who became active users as well as user surveys and a case study. Utility was measured in terms of the type of work that the Learning Exchange facilitated for the community. Results The ICNExchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. Conclusions The ICNExchange is acceptable, feasible, and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICNExchange suggests that the design principles are extensible to other chronic care Learning Networks.

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Background While the chronic care model has been extensively used for the management of patients with diabetes in non-academic, primary care settings, it is not clear whether this model can be used effectively in academic, specialty clinics for other chronic disorders. Methods Through the Academic Chronic Care Collaborative, the chronic care model was introduced to help manage patients with osteoarthritis in an academic rheumatology service with seven prespecified goals. These goals included measurements of Western Ontario MacMaster (WOMAC) osteoarthritis scores, self-efficacy scores and exercise time.Results Five a priori goals were achieved in this study: average WOMAC scores less than 1000 mm as measured on a visual analogue scale, average selfefficacy score of less than 5 mm, average exercise time greater than 90 min, more than 40% of patients exercising at least 60 min per week and a 20% improvement in self-efficacy scores. However, a 20% improvement in WOMAC scores and a 60% completion of documented self-management goals in our patients were not achieved. Our inability to achieve our selfmanagement goal underscores the fact that we have not yet fully implemented the chronic care model into our practice. The inability to detect a 20% improvement in WOMAC scores in the context of having reached our absolute WOMAC goal at baseline suggests a probable ceiling effect for this measure.Conclusions The chronic care model can be effectively introduced into an academic specialty service and can be used effectively in the management of patients with nondiabetic disorders, in this case osteoarthritis.Osteoarthritis is a common chronic medical condition. The number of people in the USA affected with this disorder is expected to increase from 40 million in 1995 (15% of the population) to 59 million in 2020 (18% of the population).1 It is associated with substantial costs to the individual (pain, functional impairment and reduced quality of life) and to society (disability and loss of productivity). Despite its high prevalence and social burden, there are no disease-modifying medications for osteoarthritis. 2There are, fortunately, effective pharmacologic and non-pharmacologic treatments that can help patients with osteoarthritis. Weight reduction and exercise are two of the more important nonpharmacologic treatments that motivated patients can use to help ameliorate their problems.3 There are significant barriers, however, to the use of pharmacologic (risk of complications with the use of non-steroidal anti-inflammatory agents in older persons) and non-pharmacologic treatments (reluctance to exercise a joint affected with osteoarthritis 4 ). The chronic care model may be useful in such a setting. According to this model, optimal care can be achieved when a prepared practice team interacts with an activated patient. 5 There are six key elements to the chronic care model. Selfmanagement support is, for example, one of these elements that can effectively empower patients to overcome obstacles and deal with their he...

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