This proposal aims to help accelerate the transition to a higher performing healthcare system by studying important clinical conditions to advance our understanding of the factors that influence the implementation of innovations - evidence-based and less so - in healthcare.  The research extends collaborations between Dartmouth, the University of California at Berkeley, Harvard, and the High Value Healthcare Collaborative.  The findings will help guide the development and use of evidence from patient-centered outcomes research.  The research is rooted in three frameworks.  First, we recognize the key role of four major factors that influence the implementation of innovations: the external environment (e.g., state policies), the characteristics of the organizations adopting the innovation (e.g., degree of integration), the internal organizational processes selected to implement the innovations (e.g., physician payment), and the characteristics of the innovation itself.  Second, we acknowledge the diversity of innovations; the relative importance of different factors that influence adoption may vary across the key decision-makers involved: biomedical innovations target diseases and are generally adopted by physicians; care delivery innovations target patient groups defined by function or illness severity and are largely adopted by managers; patient engagement innovations focus on changing patient roles.  Third, different types of organizations may be more or less able to respond to external influences or adopt different internal processes to improve care.  The approach builds on these frameworks to study the use of innovations and their impact on health, health care and costs.  The Data Core will conduct a National Survey of Healthcare Organizations and Systems and will identify, track and characterize health systems, and measure their performance through national and clinically enriched databases.  Project One will evaluate how environmental factors influence clinical integration, adoption of new payment models, and how Organizations use evidence: Project Two will evaluate the internal mechanisms that health systems use to increase clinicians' adoption of evidence-based practices and how and why systems adopt these approaches.  Project Three will study the factors that influence the use of more or less effective biomedical innovations.  Project Four will study the factors that influence the use of care delivery innovations and how the implementation of these innovations can be improved.  Project Five examines the environmental and organizational factors associated with the use of interventions to enhance patient engagement and measure patient-centered outcomes of care.