In March of 1997, the National Research Council (NRC) of
the National Academy of Sciences issued the report, “For the Record:
Protecting Electronic Health Information.” Concluding that the current
practices at the majority of health care facilities in the United States are
insufficient, the Council delineated both technical and organizational
approaches to protecting electronic health information. The Beth Israel
Deaconess Medical Center recently implemented a proof-of-concept, Web-based,
cross-institutional medical record, CareWeb, which incorporates the NRC
security and confidentiality recommendations. We report on our WWW
implementation of the NRC recommendations and an initial evaluation of the
balance between ease of use and confidentiality.
Information technology can support the implementation of clinical research findings in practice settings. Technology can address the quality gap in health care by providing automated decision support to clinicians that integrates guideline knowledge with electronic patient data to present real-time, patient-specific recommendations. However, technical success in implementing decision support systems may not translate directly into system use by clinicians. Successful technology integration into clinical work settings requires explicit attention to the organizational context. We describe the application of a “sociotechnical” approach to integration of ATHENA DSS, a decision support system for the treatment of hypertension, into geographically dispersed primary care clinics. We applied an iterative technical design in response to organizational input and obtained ongoing endorsements of the project by the organization's administrative and clinical leadership. Conscious attention to organizational context at the time of development, deployment, and maintenance of the system was associated with extensive clinician use of the system.
Providing patients with access to their electronic health records offers great promise to improve patient health and satisfaction with their care, as well to improve professional and organizational approaches to health care. Although many benefits have been identified, there are many questions about best practices for the implementation of patient accessible Electronic Health Records (EHRs).
To develop recommendations to assist health care organizations in providing patients with access to EHRs in a meaningful, responsible, and responsive manner.
A Patient Accessible Electronic Health Record (PAEHR) Workshop was held with nationally and internationally renowned experts to explore issues related to providing patient access to the EHR and managing institutional change.
The PAEHR Workshop was attended by 45 participants who discussed recommendations for the implementation of patient accessible EHRs. Recommendations were discussed under four subject domains: (1) providing patient access to the EHR, (2) maintaining privacy and confidentiality related to the PAEHR, (3) patient education and navigation of the PAEHR, and (4) strategies for managing institutional change. The discussion focused on the need for national infrastructure, clear definitions for privacy, security and confidentiality, flexible, interoperable solutions, and patient and professional education. In addition, there was a strong call for research into all domains of patient accessible EHRs to ensure the adoption of evidence-based practices.
Patient access to personal health information is a fundamental issue for patient engagement and empowerment. Health care professionals and organizations should consider the potential benefits and risks of patient access when developing EHR strategies. Flexible, standardized, and interoperable solutions must be integrated with outcomes-based research to activate effectively patients as partners in their health care.
Electronic Health Record (EHR); Personal Health Record (PHR); medical records; recommendations; health planning guidelines; access; access to information
A large number of health information system (HIS) implementations fail due to insufficient organizational harmonization. The aim of this study is to examine whether these problems remain when implementing technically integrated and more advanced generations of HIS. In a case study, data from observations, interviews, and organizational documents were analyzed using qualitative methods. We found that critical issues in the case study implementation process were the techniques employed to teach the staff to use the integrated system, involvement of the users in the implementation process, and the efficiency of the human computer interface. Comparisons with a literature review showed both recurrence of previously reported implementation problems and new issues specific to the integrated system context. The results indicate that the development of evidence-based implementation processes should be considered.
People and organizational issues are critical in both
implementing medical informatics systems and in dealing with the altered
organizations that new systems often create. The people and organizational
issues area—like medical informatics itself—is a blend of many
disciplines. The academic disciplines of psychology, sociology, social
psychology, social anthropology, organizational behavior and organizational
development, management, and cognitive sciences are rich with research with
significant potential to ease the introduction and on-going use of information
technology in today's complex health systems. These academic areas contribute
research data and core information for better understanding of such issues as
the importance of and processes for creating future direction; managing a
complex change process; effective strategies for involving individuals and
groups in the informatics effort; and effectively managing the altered
organization. This article reviews the behavioral and business referent
disciplines that can potentially contribute to improved implementations and
on-going management of change in the medical informatics arena.
The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.
health information technology; implementation; barriers; facilitators; EMR; organizational culture
Determine the degree to which AACP member schools have established professional practice plans, characterize the nature of existing practice plans, and provide recommendations on the implementation of practice plans at AACP member schools.
Survey of CEO Deans of AACP member institutions administered via online survey instrument.
Sixty-five schools responded, with 29 (45%) indicating that they had an active practice plan in place. Fifty-two percent of those who do no have practice plans in place anticipate having plans established within three years. A variety of revenue sources are addressed by existing practice plans including sponsored research, patient care, educational activities and consulting.
Academic pharmacy lacks sophistication in regards to developing comprehensive professional practice plans. Colleges of pharmacy should consider differentiating plans that address monies collected from sponsored research vs. professional services. AACP should continue to monitor this topic as increasing participation by member schools is expected.
practice plans; faculty consulting; clinical services; faculty-generated revenue
The advent of electronic personal health records (PHR) provides a major opportunity to encourage positive health management practices, such as chronic disease management. Yet, to date there has been little attention toward the use of PHRs where advanced health information services are perhaps most needed, namely, in underserved communities. Drawing upon research conducted with safety net providers and patients, the authors propose a multi-level analytical framework for guiding actions aimed at fostering PHR adoption and utilization. The authors first outline distinctive user and technical requirements that need to be considered. Next, they assess organizational requirements necessary to implement PHRs within health systems bound by limited resources. Finally, the authors analyze the overriding health care policy context that can facilitate or thwart such efforts. The conclusion notes that heightened national attention toward health information technology and reform provides a significant opportunity for initiatives whose goal is to increase widepread access to PHRs.
Medically underserved; chronically ill; personal health records
Background: The National Research Council (NRC) of the National Academy of Sciences recently published the report Exposure Science in the 21st Century: A Vision and a Strategy. The expert committee undertaking this report included expertise from ecology, chemistry, exposure science, toxicology, public health, bioethics, engineering, medicine, and policy.
Objective: Our aim is to inform members of the scientific community in fields aligned with environmental and public health so they are more able to appreciate the full breadth of the vision and understand the framework developed in order to move the vision forward.
Discussion: Although the NRC report was commissioned by the U.S. Environmental Protection Agency and the National Institute of Environmental Health Sciences, it is solely the consensus product of the independent volunteer committee, whose findings were subject to the rigorous peer-review procedures of the NRC. In addition to reviewing the history and current status of exposure science, the report lays out a vision for the future and makes recommendations that include both short-term and long-term milestones.
Conclusion: To accomplish the vision presented in the NRC report, resources will be needed to complete studies, develop and use analyses of exposure, and build databases associated with individual and population exposures, as well as to train the next generation of exposure scientists. Important excerpts as well as paraphrased statements from the report appear in this commentary; however, the general observations and comments are our own.
eco-exposome; exposome; exposure assessment; exposure science; National Research Council
As increasingly powerful informatics systems are designed, developed, and implemented, they inevitably affect larger, more heterogeneous groups of people and more organizational areas. In turn, the major challenges to system success are often more behavioral than technical. Successfully introducing such systems into complex health care organizations requires an effective blend of good technical and good organizational skills. People who have low psychological ownership in a system and who vigorously resist its implementation can bring a “technically best” system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change—including to new technologies—to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.
There is a critical gap in our nation's ability to accurately measure and manage the quality of medical care. A robust healthcare quality information system (HQIS) has the potential to address this deficiency through the capture, codification, and analysis of information about patient treatments and related outcomes. Because non-technical issues often present the greatest challenges, this paper provides an overview of these socio-technical issues in building a successful HQIS, including the human, organizational, and knowledge management (KM) perspectives. Through an extensive literature review and direct experience in building a practical HQIS (the National Comprehensive Cancer Network Outcomes Research Database system), we have formulated an “informatics blueprint” to guide the development of such systems. While the blueprint was developed to facilitate healthcare quality information collection, management, analysis, and reporting, the concepts and advice provided may be extensible to the development of other types of clinical research information systems.
Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.
A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.
A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.
Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.
Most studies of the impact of information systems in organizations tend to see the implementation process as a “rollout” of technology, as a technical matter removed from organizational dynamics. There is substantial agreement that the success of implementing information systems is determined by organizational factors. However, it is less clear what these factors are. The authors propose to characterize the introduction of an information system as a process of mutual shaping. As a result, both the technology and the practice supported by the technology are transformed, and specific technical and social outcomes gradually emerge. The authors suggest that insights from social studies of science and technology can help to understand an implementation process. Focusing on three theoretical aspects, the authors argue first that the implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Second, following Orlikowski's concept of “emergent change,” they suggest that implementing a system is, by its very nature, unpredictable. Third, they argue that success and failure are not dichotomous and static categories, but socially negotiated judgments. Using these insights, the authors have analyzed the implementation of a computerized physician order entry (CPOE) system in a large Dutch university medical center. During the course of this study, the full implementation of CPOE was halted, but the aborted implementation exposed issues on which the authors did not initially focus.
Promotores are community lay health workers, who provide outreach and services to Latinos. Little research on the promotores programs exists and the focus of this article is to identify the challenges faced by community-based nonprofits when implementing promotores programs. To explore this type of program telephone interviews were conducted with ten promotores academic experts and nonprofit executives. The results suggest that implementation challenges fall into three major categories: the lack of standardized information on promotores programs, labor issues, and organizational costs. Future recommendations are made which highlight promotores recruitment and retention strategies, and the development of a clearinghouse of programmatic implementation information for community-based nonprofits.
community-based health delivery; promotores programs; Latino health; nonprofit organizational implementation
A decrease in medical practice variations in national breast cancer care has been shown to improve survival and the negative impact of the disease on affected women and their families. The following report describes the concert of efforts undertaken by the medical societies to optimize national breast cancer care by organizational centralization of multidisciplinary medical competence in certified breast centers (CBC), aiming to attain continual quality of health care by implementation of evidence-and consensus-based guidelines. Centralization and the systematic pursuit of organizational development by tracking guideline adherence using performance quality indicators over time demonstrate the feasibility and practicability of the implementation concept to bridge the gap between determined scientific best evidence and applied best practice. However, the proof of concept will remain pending until the data of the population-based cancer registries are analyzed for survival estimates.
Breast neoplasms; Breast center; Certification; Guidelines; Quality of care
Organizational benefits of diversity in the workplace have been well documented. In health professions, however, diversity-related research traditionally has focused on the effect of diversity on health care disparities. Few tools exist describing the benefits of diversity from an organizational standpoint to guide pharmacy administrators and faculty members in nurturing and developing a culture of diversity. Given the scarcity of pharmacy specific data, experience from other academic areas and national/international diversity reports were incorporated into this manuscript to supplement the available pharmacy evidence base. This review summarizes the benefits of diversity from an academic organizational standpoint, discusses the issues administrators and faculty members must consider when developing programs, and provides guidance on best practices in fostering and managing diversity.
diversity; health care disparities; minority; cultural competence
This article outlines the development of the National Advisory Council on Family Medicine Training as based on the recommendations of the Canadian Medical Association Task Force on Education for the Provision of Primary Care Services and its report Family Practice Training: Continuing the Evolution. The changes that were recommended in the composition and mandate of the Council are outlined, as well as the Council's current and continuing activities.
National Advisory Council on Family Medicine Training; Canadian Medical Association Task Force on Education for the Provision of Primary Care Services; education
Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices through observational study.
Three site visits were conducted at institutions across the USA to learn about CDS capabilities and processes from clinical, technical, and organizational perspectives. Based on the results of these visits, written questionnaires were sent to the three institutions visited and two additional sites. Together, these five organizations encompass a variety of academic and community hospitals as well as small and large ambulatory practices. These organizations use both commercially available and internally developed clinical information systems.
Characteristics of clinical information systems and CDS systems used at each site as well as governance structures and content management approaches were identified through extensive field interviews and follow-up surveys.
Six recommended practices were identified in the area of governance, and four were identified in the area of content management. Key similarities and differences between the organizations studied were also highlighted.
Each of the five sites studied contributed to the recommended practices presented in this paper for CDS governance. Since these strategies appear to be useful at a diverse range of institutions, they should be considered by any future implementers of decision support.
Mental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians. However, implementation is known to be dependent upon a broader ecology of service delivery. Hence, focusing exclusively on individual clinicians as targets of implementation is unlikely to result in sustainable and widespread implementation of EBPs.
Policymaking that is informed by the implementation literature requires that policymakers deploy strategies across multiple levels of the ecology of implementation. At the organizational level, policies are needed to resource the added marginal costs of EBPs, and to assist organizational learning by re-engineering continuing education units. At the payor and regulatory levels, policies are needed to creatively utilize contractual mechanisms, develop disease management programs and similar comprehensive care management approaches, carefully utilize provider and organizational profiling, and develop outcomes assessment. At the political level, legislation is required to promote mental health parity, reduce discrimination, and support loan forgiveness programs. Regulations are also needed to enhance consumer and family engagement in an EBP agenda. And at the social level, approaches to combat stigma are needed to ensure that individuals with mental health need access services.
The implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation. Policymaking that addresses in an integrated way the ecology of implementation at the levels of provider organizations, governmental regulatory agencies, and their surrounding political and societal milieu is required to successfully and sustainably implement EBPs over the long term.
Background: Major reviews of the health effects of passive smoking have been subjected to tobacco industry campaigns to refute the scientific evidence. Following the 1992 US Environmental Protection Agency review, the Australian National Health and Medical Research Council (NHMRC) initiated a review of the health effects of passive smoking. At the time of this review, evidence that environmental tobacco smoke causes disease was being increasingly accepted in courts of law and voluntary adoption of smoking restrictions was rapidly growing.
Objective: To demonstrate how the tobacco industry attempted to delay and discredit the publication of a report on passive smoking that the tobacco industry anticipated to contain recommendations that would be unfavourable to their business.
Methods: A search of tobacco industry documents on the Master Settlement Agreement websites was conducted using the terms and acronyms representative of the NHMRC review.
Results: The tobacco industry sought to impede the progress of the NHMRC Working Party by launching an intensive campaign to delay and discredit the report. The main strategies used were attempts to criticise the science, extensive use of Freedom of Information provisions to monitor all activity of the group, legal challenges, ad hominem attacks on the credibility of the Working Party members, rallying support from industry allies, and influencing public opinion through the media.
Conclusions: The Australian tobacco industry deliberately impeded the NHMRC Working Party's progress and successfully prevented the publication of the report's recommendations. The tobacco industry's motivation and capacity to disrupt the advancement of scientific knowledge and policy in tobacco control should be recognised and anticipated.
Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted “socio-technical” approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.
BACKGROUND: Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based. METHODS: Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews. RESULTS: Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity. INTERPRETATION: The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.
Individuals, families and communities in Northern Sri Lanka have undergone three decades of war trauma, multiple displacements, and loss of family, kin, friends, homes, employment and other valued resources. The objective of the study was understanding common psychosocial problems faced by families and communities, and the associated risk and protective factors, so that practical and effective community based interventions can be recommended to rebuild strengths, adaptation, coping strategies and resilience.
This qualitative, ecological study is a psychosocial ethnography in post-war Northern Sri Lanka obtained through participant observation; case studies; key- informant interviews; and focus groups discussions with mental health and psychosocial community workers as well as literature survey of media and organizational reports. Qualitative analysis of the data used ethnography, case studies, phenomenology, grounded theory, hermeneutics and symbolic interactionism techniques. Quantitative data on suicide was collected for Jaffna and Killinochchi districts.
Complex mental health and psychosocial problems at the individual, family and community levels in a post-war context were found to impair recovery. These included unresolved grief; individual and collective trauma; insecurity, self-harm and suicides; poverty and unemployment; teenage and unwanted pregnancies; alcoholism; child abuse and neglect; gender based violence and vulnerability including domestic violence, widows and female headed-household, family conflict and separation; physical injuries and handicap; problems specific for children and elderly; abuse and/or neglect of elderly and disabled; anti-social and socially irresponsible behaviour; distrust, hopelessness, and powerlessness. Protective factors included families; female leadership and engagement; cultural and traditional beliefs, practices and rituals; and creative potential in narratives, drama and other arts. Risk factors that were impeding community rehabilitation and recovery included continuing military governance, depletion of social capital particularly lack of trust, hope and socio-economic opportunity structures for development that would engender a sense of collective efficacy.
In view of the widespread trauma at the individual, family and collective levels, community based programmes to increase local awareness, knowledge and skills to deal with common mental health and psychosocial issues; and training of community level workers and others in basic mental health and psychosocial problem solving are recommended to rebuild family and community agency and resilience. The use of cultural practices and school based programmes would rekindle community processes.
Collective trauma; Community resilience; Post-war; Post-conflict; Psychosocial; Community based interventions
The context of healthcare organizations such as hospitals is increasingly accepted as having the potential to influence the use of new knowledge. However, the mechanisms by which the organizational context influences evidence-based practices are not well understood. Current measures of organizational context lack a theory-informed approach, lack construct clarity and generally have modest psychometric properties. This paper presents the development and initial psychometric validation of the Alberta Context Tool (ACT), an eight dimension measure of organizational context for healthcare settings.
Three principles guided the development of the ACT: substantive theory, brevity, and modifiability. The Promoting Action on Research Implementation in Health Services (PARiHS) framework and related literature were used to guide selection of items in the ACT. The ACT was required to be brief enough to be tolerated in busy and resource stretched work settings and to assess concepts of organizational context that were potentially modifiable. The English version of the ACT was completed by 764 nurses (752 valid responses) working in seven Canadian pediatric care hospitals as part of its initial validation. Cronbach's alpha, exploratory factor analysis, analysis of variance, and tests of association were used to assess instrument reliability and validity.
Factor analysis indicated a 13-factor solution (accounting for 59.26% of the variance in 'organizational context'). The composition of the factors was similar to those originally conceptualized. Cronbach's alpha for the 13 factors ranged from .54 to .91 with 4 factors performing below the commonly accepted alpha cut off of .70. Bivariate associations between instrumental research utilization levels (which the ACT was developed to predict) and the ACT's 13 factors were statistically significant at the 5% level for 12 of the 13 factors. Each factor also showed a trend of increasing mean score ranging from the lowest level to the highest level of instrumental research use, indicating construct validity.
To date, no completely satisfactory measures of organizational context are available for use in healthcare. The ACT assesses several core domains to provide a comprehensive account of organizational context in healthcare settings. The tool's strengths are its brevity (allowing it to be completed in busy healthcare settings) and its focus on dimensions of organizational context that are modifiable. Refinements of the instrument for acute, long term care, and home care settings are ongoing.
Treatment programs are expected to change their clients. To adopt evidence-based practices to improve their therapeutic effectiveness in dealing with drug-related problems of clients, they also are expected to change themselves. The process of innovation adoption and implementation is the focus of studies included in this special journal issue. Collectively, this volume examines staff perceptions of program needs, organizational readiness for change (based on pressures, resources, staff attributes, and organizational climate), quality of workshop training, subsequent utilization of training materials, and client self-report of treatment engagement. Approximately 800 treatment programs nationwide contributed data for these studies. A standardized assessment of organizational functioning captured attributes that describe environments, settings, and staffs, and the findings are interpreted in the context of a stage-based approach to program changes. A conceptual model is used to help organize and summarize longitudinal results within the organizational context and according to implementation influences related to qualities of the innovations.
Evidence-based practice; Innovation; Program change; Organizational functioning; Implementation process