For more than a decade, many have argued for the vision of a **learning healthcare system**, "designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in healthcare". [@olsen2007learning] A chief component of this ambition rests on the exciting prospect that patient-level data captured during the routine course of clinical care could be analyzed to produce **real-world evidence**, which in turn could be disseminated across the healthcare system to inform clinical practice. In 2007, the Institute of Medicine Roundtable on Evidence-Based Medicine issued a report which established a goal that "By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence." [@olsen2007learning] While tremendous progress has been made on many different fronts, we still fall well short of these laudable aspirations.
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