Exploring Barriers, Enablers, and Strategies for Implementing Learning Health System Projects in Healthcare Organizations: A Multilevel Analysis in an Australian Setting.

Objective: To analyze the barriers, enablers, and strategies affecting the implementation of learning health systems (LHS) projects across individual (micro), organizational (meso), and system (macro) levels within Australian healthcare settings. Methods: Semistructured interviews were conducted with 26 clinicians undertaking LHS projects in their organizations, as part of a LHS Academy fellowship program. Interviews were completed at two discrete time points: early in project implementation and again at project completion. They explored fellows' experiences with implementing LHS projects in real-world organizational contexts. Data were analyzed using a hybrid deductive-inductive approach guided by a multilevel ecological codebook developed by Shaw et al. Results: Participants' early interviews highlighted limited confidence, emerging leadership skills, and uncertainty in navigating implementation challenges, while later interviews described greater confidence, stronger leadership capability, and more refined adaptive strategies at the micro level. Organizational influences were described at both time points as slow and uneven, though later interviews included examples of small cultural shifts and early collaborative efforts alongside persistent constraints such as limited resources, siloed cultures, and inadequate digital infrastructure. At the system level, barriers including regulatory complexity, policy misalignment, and limited funding were reported consistently across both interviews and were perceived as largely unchanged. Conclusions: Building individual capability was necessary but insufficient for successful LHS project implementation. Alignment across micro-, meso-, and macrolevels is critical, requiring parallel investment in organizational readiness, digital infrastructure, and policy reform. Fellowship programs may support individual change and foster proof-of-concept projects, but scaling impact demands coordinated, multilevel strategies.