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1.  High Performance in Screening for Colorectal Cancer: A Practice Partner Research Network (PPRNet) Case Study 
Introduction
Colorectal cancer (CRC) screening is recommended for average risk adults age 50 and older, yet half of eligible US adults are not current. Competing demands within primary care suggest a systematic process is needed for improvement. This case study of highest performing practices within the Colorectal Screening in Primary Care study (C-TRIP) explains practice strategies used and provides a model for improving CRC screening in primary care.
Methods
A case study design was used to analyze practice performance data and qualitative data obtained from site visits, network meetings and correspondence. The Practice Partner Research Network (PPRNet) Translating Research into Practice (TRIP) Quality Improvement (QI) model provided an analytic framework to evaluate five highest performing practices in the C-TRIP intervention. Practice strategies were grouped within the concepts: prioritize performance (PP), redesign delivery system (RDS), electronic medical record tools (EMR), and activate the patient (AP).
Results
Thirteen specific practice strategies were exemplified within these four concepts (PP, RDS, EMR, AP). Most or all of these strategies were used by the practices that achieved a rate of up to 78% of adults screened for CRC.
Conclusions
Primary care practices achieving a high proportion of CRC screening use systematic processes in the organization of their care. This case study provides a framework to organize systems that increase early detection and prevention of colorectal cancer.
doi:10.3122/jabfm.2009.02.080108
PMCID: PMC2696281  PMID: 19264937
colorectal cancer screening; primary care; quality improvement; practice-based research
2.  Embedding effective depression care: using theory for primary care organisational and systems change 
Background
Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.
Methods
We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.
Results
Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.
Conclusions
Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.
doi:10.1186/1748-5908-5-62
PMCID: PMC2925331  PMID: 20687962
3.  Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home 
Quality in Primary Care  2011;19(5):289-300.
Background
Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice.
Methods
Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed.
Results
Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy.
Practice Implications
Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts.
PMCID: PMC3313551  PMID: 22186171
primary care practice; quality improvement; qualitative analysis
4.  Clinical Effort Against Secondhand Smoke Exposure (CEASE): Development of Framework and Intervention 
Pediatrics  2008;122(2):e363-e375.
Objective
To describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.
Methodology
The scientific development of the intervention occurred in three stages. In stage one, we designed an office system for parental tobacco control in the pediatric outpatient setting based on complementary conceptual frameworks of preventive services delivery, conceptualized for the child healthcare setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidenced-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage two, we performed focus group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype based on this feedback to include five key implementation steps for the child healthcare setting. In stage three, we presented the intervention to breakout groups at two national meetings of pediatric practitioners for further refinements.
Results
The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The CEASE intervention is designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practices can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).
Conclusions
Conceptually-grounded and focus group tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco control intervention development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.
doi:10.1542/peds.2008-0478
PMCID: PMC2774730  PMID: 18676523
smoking; tobacco; pediatrics; family practice; parent; smoking cessation; secondhand smoke; environmental tobacco smoke; tobacco control; quitline; telephone counseling
5.  The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence 
Background
The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.
Objective
The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.
Materials and methods
Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.
Results and discussion
The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian's framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.
doi:10.1136/amiajnl-2010-000019
PMCID: PMC3197985  PMID: 21659445
Clinical informatics; quality of healthcare; systematic review; machine learning; health data standards; vocabulary; ontology; scientific information and health data policy; consumer health/patient education information; information retrieval; NLP; public health informatics; clinical trials; electronic medical records; primary care; systematic review
6.  Physician perceptions of primary prevention: qualitative base for the conceptual shaping of a practice intervention tool 
BMC Public Health  2002;2:16.
Background
A practice intervention must have its basis in an understanding of the physician and practice to secure its benefit and relevancy. We used a formative process to characterize primary care physician attitudes, needs, and practice obstacles regarding primary prevention. The characterization will provide the conceptual framework for the development of a practice tool to facilitate routine delivery of primary preventive care.
Methods
A focus group of primary care physician Opinion Leaders was audio-taped, transcribed, and qualitatively analyzed to identify emergent themes that described physicians' perceptions of prevention in daily practice.
Results
The conceptual worth of primary prevention, including behavioral counseling, was high, but its practice was significantly countered by the predominant clinical emphasis on and rewards for secondary care. In addition, lack of health behavior training, perceived low self-efficacy, and patient resistance to change were key deterrents to primary prevention delivery. Also, the preventive focus in primary care is not on cancer, but on predominant chronic nonmalignant conditions.
Conclusions
The success of the future practice tool will be largely dependent on its ability to "fit" primary prevention into the clinical culture of diagnoses and treatment sustained by physicians, patients, and payers. The tool's message output must be formatted to facilitate physician delivery of patient-tailored behavioral counseling in an accurate, confident, and efficacious manner. Also, the tool's health behavior messages should be behavior-specific, not disease-specific, to draw on shared risk behaviors of numerous diseases and increase the likelihood of perceived salience and utility of the tool in primary care.
doi:10.1186/1471-2458-2-16
PMCID: PMC126210  PMID: 12204096
7.  Understanding general practice: a conceptual framework developed from case studies in the UK NHS 
Background
General practice in the UK is undergoing a period of rapid and profound change. Traditionally, research into the effects of change on general practice has tended to regard GPs as individuals or as members of a professional group. To understand the impact of change, general practices should also be considered as organisations.
Aim
To use the organisational studies literature to build a conceptual framework of general practice organisations, and to test and develop this empirically using case studies of change in practice. This study used the implementation of National Service Frameworks (NSFs) and the new General Medical Services (GMS) contract as incidents of change.
Design of study
In-depth, qualitative case studies. The design was iterative: each case study was followed by a review of the theoretical ideas. The final conceptual framework was the result of the dynamic interplay between theory and empirical evidence.
Setting
Five general practices in England, selected using purposeful sampling.
Method
Semi-structured interviews with all clinical and managerial personnel in each practice, participant and non-participant observation, and examination of documents.
Results
A conceptual framework was developed that can be used to understand how and why practices respond to change. This framework enabled understanding of observed reactions to the introduction of NSFs and the new GMS contract. Important factors for generating responses to change included the story that the practice members told about their practice, beliefs about what counted as legitimate work, the role played by the manager, and previous experiences of change.
Conclusion
Viewing general practices as small organisations has generated insights into factors that influence responses to change. Change tends to occur from the bottom up and is determined by beliefs about organisational reality. The conceptual framework suggests some questions that can be asked of practices to explain this internal reality.
PMCID: PMC2032702  PMID: 17244426
change; conceptual framework; general practice; organisations
8.  Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study 
ABSTRACT
BACKGROUND
Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).
OBJECTIVE
To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.
DESIGN
A two-phase, 27-month demonstration project.
SETTING
Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).
PARTICIPANTS
Thirty-nine providers were included in the project.
INTERVENTION
A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.
MAIN OUTCOME MEASURES
1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.
KEY RESULTS
The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57 % [95 % CI, −5.35 %, 8.49 %] in adults and −1.89 % [95 % CI, −9.03 %, 5.26 %] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, −16.30 %, [95 % CI, −24.81 %, −7.79 %] in adults and −16.30 [95%CI, −23.29 %, −9.31 %] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.
CONCLUSIONS
This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.
doi:10.1007/s11606-012-2267-2
PMCID: PMC3663943  PMID: 23117955
acute respiratory infections; antibiotic prescribing; electronic health records; clinical decision support
9.  Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings 
Background
Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.
Methods/Design
Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines—staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers’ tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.
Discussion
We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.
Trial registration
NCT01615237.
doi:10.1186/1748-5908-9-25
PMCID: PMC3936874  PMID: 24559178
Dental care; Clinical practice guidelines; Treatment of tobacco dependence; Tobacco cessation
10.  Patient Safety Perceptions of Primary Care Providers after Implementation of an Electronic Medical Record System 
ABSTRACT
BACKGROUND
Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety.
OBJECTIVE
To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation.
DESIGN
Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.5 (T2) and 2.5 (T3) years post-implementation. The SAQ was supplemented with a practice-specific assessment tool to identify safety needs and barriers.
PARTICIPANTS
A large medical group practice with a primary care core of 17–18 practices, staffed by clinicians in family medicine, pediatrics, internal medicine.
INTERVENTIONS
Survey results were used to define and respond to areas of need between assessments with system changes and educational programs.
MAIN MEASURES
Change in safety culture over time; perceived impact of EMR on practice.
KEY RESULTS
Responses were received from 103 of 123 primary care providers in T1 (83.7 % response rate), 122 of 143 in T2 (85.3 %) and 142 of 181 in T3 (78.5 %). Safety culture improved over this period, with statistically significant improvement in all domains except for stress recognition. Time constraints, communications and patient adherence were perceived to be the most important safety issues. The majority of respondents in both T2 (77.9 %) and T3 (85.4 %) surveys agreed that the EMR improved their ability to provide care more safely.
CONCLUSIONS
Implementation of an EMR in a large primary care practice required redesign of many organizational processes, and was associated with improvements in safety culture. Most primary care providers agreed that the EMR allowed them to provide care more safely.
doi:10.1007/s11606-012-2153-y
PMCID: PMC3614133  PMID: 22887020
electronic medical records; EMR; safety culture; primary care; safety attitudes questionnaire
11.  Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID) 
Background
Assessing the quality of primary care is becoming a priority in national healthcare agendas. Audit and feedback on healthcare quality performance indicators can help improve the quality of care provided. In some instances, fewer numbers of more comprehensive indicators may be preferable. This paper describes the use of the Summary Quality Index (SQUID) in tracking quality of care among patients and primary care practices that use an electronic medical record (EMR). All practices are part of the Practice Partner Research Network, representing over 100 ambulatory care practices throughout the United States.
Methods
The SQUID is comprised of 36 process and outcome measures, all of which are obtained from the EMR. This paper describes algorithms for the SQUID calculations, various statistical properties, and use of the SQUID within the context of a multi-practice quality improvement (QI) project.
Results
At any given time point, the patient-level SQUID reflects the proportion of recommended care received, while the practice-level SQUID reflects the average proportion of recommended care received by that practice's patients. Using quarterly reports, practice- and patient-level SQUIDs are provided routinely to practices within the network. The SQUID is responsive, exhibiting highly significant (p < 0.0001) increases during a major QI initiative, and its internal consistency is excellent (Cronbach's alpha = 0.93). Feedback from physicians has been extremely positive, providing a high degree of face validity.
Conclusion
The SQUID algorithm is feasible and straightforward, and provides a useful QI tool. Its statistical properties and clear interpretation make it appealing to providers, health plans, and researchers.
doi:10.1186/1748-5908-2-11
PMCID: PMC1852570  PMID: 17407560
12.  Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative Care 
Diabetes technology & therapeutics  2006;8(5):10.1089/dia.2006.8.576.
Background
Despite the availability of expert guidelines and widespread diabetes quality improvement efforts, care of patients with diabetes remains suboptimal. Two key barriers to care that may be amenable to informatics-based interventions include (1) lack of patient engagement with therapeutic care plans and (2) lack of medication adjustment by physicians (“clinical inertia”) during clinical encounters.
Methods
The authors describe the conceptual framework, design, implementation, and analysis plan for a diabetes patient web-portal linked directly to the electronic health record (EHR) of a large academic medical center via secure Internet access designed to overcome barriers to effective diabetes care.
Results
Partners HealthCare System (Boston, MA), a multi-hospital health care network comprising several thousand physicians caring for over 1 million individual patients, has developed a comprehensive patient web-portal called Patient Gateway that allows patients to interact directly with their EHR via secure Internet access. Using this portal, a specific diabetes interface was designed to maximize patient engagement by importing the patient's current clinical data in an educational format, providing patient-tailored decision support, and enabling the patient to author a “Diabetes Care Plan.” The physician view of the patient's Diabetes Care Plan was designed to be concise and to fit into typical EHR clinical workflow.
Conclusions
We successfully designed and implemented a Diabetes Patient portal that allows direct interaction with our system's EHR. We are assessing the impact of this advanced informatics tool for collaborative diabetes care in a clinic-randomized controlled trial among 14 primary care practices within our integrated health care system.
doi:10.1089/dia.2006.8.576
PMCID: PMC3829634  PMID: 17037972
13.  Impacts of Evidence-Based Quality Improvement on Depression in Primary Care: A Randomized Experiment 
Journal of General Internal Medicine  2006;21(10):1027-1035.
CONTEXT
Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process.
OBJECTIVE
Evaluate impacts of EBQI on practice-wide depression care and outcomes.
DESIGN
Practice-level randomized experiment comparing EBQI with usual care.
SETTING
Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients.
INTERVENTION
Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools.
EVALUATION PARTICIPANTS
Five hundred and sixty-seven representative patients with major depression.
MAIN OUTCOME MEASURES
Appropriate treatment, depression, functional status, and satisfaction.
RESULTS
Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months, P = .07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome, P = .18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months, P = .02); physical functioning did not.
CONCLUSION
Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.
doi:10.1111/j.1525-1497.2006.00549.x
PMCID: PMC1831644  PMID: 16836631
quality improvement; depression; continuous quality management; social function
14.  Implementation Interventions Used in Nursing Homes and Hospitals: A Descriptive, Comparative Study between Austria, Germany, and The Netherlands 
ISRN Nursing  2013;2013:706054.
Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.
doi:10.1155/2013/706054
PMCID: PMC3727135  PMID: 23956875
15.  A Randomized Trial Using Computerized Decision Support to Improve Treatment of Major Depression in Primary Care 
OBJECTIVE
To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression.
DESIGN
Randomized controlled trial.
SETTING
Academically affiliated primary care practice in Pittsburgh, PA.
PATIENTS
Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria.
INTERVENTION
PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: “active care” (AC), “passive care” (PC), or “usual care” (UC).
MEASUREMENTS AND MAIN RESULTS
Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D ≤7). Patients' mean HRS-D score decreased regardless of their PCPs' guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P < .001). However, neither continuous (HRS-D ≤7: 22% AC, 23% PC, 22% UC; P = .8) nor categorical measures of recovery (P = .2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in ≥3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P = .09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P = .3).
CONCLUSIONS
Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.
doi:10.1046/j.1525-1497.2002.10421.x
PMCID: PMC1495078  PMID: 12133139
major depression; PRIME-MD; primary care; electronic medical records; clinical practice guidelines; intervention
16.  Comparing user acceptance of a computer system in two pediatric offices: a qualitative study. 
The purpose of this qualitative study was to examine user acceptance of a clinical computer system in two pediatric practices in the southeast. Data were gathered through interviews with practice and IS staff, observations in the clinical area, and review of system implementation records. Five months after implementation, Practice A continued to use the system but Practice B had quit using it because it was unacceptable to the users. The results are presented here, in relation to a conceptual framework, which was originally developed to describe the process of successful implementation of research findings into practice. Five main themes were identified relative to the differences in user acceptance at the two practices: 1) Benefits versus expense of system use varied, 2) Organizational cultures differed, 3) IS staff's relationship with practices differed, 4) Post-implementation experiences differed, and 5) Transfer of technology from the academic center to private practice proved challenging in Practice B. The findings indicate a need for the development and validation of tools to measure healthcare organizational climate and readiness for change.
PMCID: PMC2243727  PMID: 11080005
17.  Welcome to Implementation Science 
Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care. This relatively new field includes the study of influences on healthcare professional and organisational behaviour.
Implementation Science will encompass all aspects of research in this field, in clinical, community and policy contexts. This online journal will provide a unique platform for this type of research and will publish a broad range of articles – study protocols, debate, theoretical and conceptual articles, rigorous evaluations of the process of change, and articles on methodology and rigorously developed tools – that will enhance the development and refinement of implementation research. No one discipline, research design, or paradigm will be favoured.
Implementation Science looks forward to receiving manuscripts that facilitate the continued development of the field, and contribute to healthcare policy and practice.
doi:10.1186/1748-5908-1-1
PMCID: PMC1436009
18.  Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study 
BMC Family Practice  2009;10:81.
Background
Fax referral services that connect smokers to state quitlines have been implemented in 49 U.S. states and territories and promoted as a simple solution to improving smoker assistance in medical practice. This study is an in-depth examination of the systems-level changes needed to implement and sustain a fax referral program in primary care.
Methods
The study involved implementation of a fax referral system paired with a chart stamp prompting providers to identify smoking patients, provide advice to quit and refer interested smokers to a state-based fax quitline. Three focus groups (n = 26) and eight key informant interviews were conducted with staff and physicians at two clinics after the intervention. We used the Chronic Care Model as a framework to analyze the data, examining how well the systems changes were implemented and the impact of these changes on care processes, and to develop recommendations for improvement.
Results
Physicians and staff described numerous benefits of the fax referral program for providers and patients but pointed out significant barriers to full implementation, including the time-consuming process of referring patients to the Quitline, substantial patient resistance, and limitations in information and care delivery systems for referring and tracking smokers. Respondents identified several strategies for improving integration, including simplification of the referral form, enhanced teamwork, formal assignment of responsibility for referrals, ongoing staff training and patient education. Improvements in Quitline feedback were needed to compensate for clinics' limited internal information systems for tracking smokers.
Conclusions
Establishing sustainable linkages to quitline services in clinical sites requires knowledge of existing patterns of care and tailored organizational changes to ensure new systems are prioritized, easily integrated into current office routines, formally assigned to specific staff members, and supported by internal systems that ensure adequate tracking and follow up of smokers. Ongoing staff training and patient self-management techniques are also needed to ease the introduction of new programs and increase their acceptability to smokers.
doi:10.1186/1471-2296-10-81
PMCID: PMC2811101  PMID: 20017930
19.  Research of organization of integrated primary care: a conceptual model 
Introduction
Primary health care in The Netherlands evolves from small general practices to multidisciplinary teams. Research on the effects on outcomes of organization of primary care is hardly available.
Aims
Develop a conceptual model to be able to systematically arrange empirical evidence on the effects of different types of organizations of integrated (primary) care.
Methods
During an expert meeting of directors of health centres we identified essential elements which they consider important for integrated primary care. Based on the outcomes of the meeting we designed a first draft of the conceptual model and completed it, based on literature.
Results and Conclusion
Based on an inventory and analysis of different definitions of primary care and integrated care, we formulated a definition of integrated primary care: ‘The smooth process of assistance and care provided by multiple disciplines within Primary Care, experienced by citizens’. The developed conceptual model contains elements to enable the delivery of integrated primary care (such as culture, professional competences, relationships and network system) and factors that affect the fluent process (such as subsequent financing, organization, ICT, legislation and regulations).
Discussion
Debate the model with participants of the conference to determine whether the model will be sufficient.
PMCID: PMC3184793
integrated primary care; inter disciplinary collaboration; conceptual model; health systems development
20.  Comparison of Electronic Physician Prompts versus Waitroom Case-Finding on Clinical Trial Enrollment 
Background
Recruiting patients into clinical research protocols is challenging. Electronic medical record (EMR) systems capable of prompting clinicians may facilitate enrollment.
Objective
To compare an EMR-based clinician prompt versus a wait-room-based case-finding strategy at enrolling patients into a clinical trial.
Design
Cross-sectional comparison of recruitment data from two trials to treat anxiety disorders in primary care. Both studies utilized similar enrollment criteria, intervention strategies, and the same four practice sites and EMR system.
Participants
Patients referred by their (primary care physicians) PCPs in response to an EMR prompt (recruited 1/2005–10/2006), and patients enrolled by research assistants stationed in practice waiting rooms (7/2000–4/2002).
Measurements
Referral counts, patients’ baseline sociodemographic and clinical characteristics.
Results
Over a 22-month period, EMR-prompted PCPs referred 794 patients and 176 (22%) met study inclusion criteria and enrolled, compared to 8,095 patients approached by wait room-based recruiters of whom 193 (2.4%) enrolled. Subjects enrolled by EMR-prompted PCPs were more likely to be non-white (23% vs 5%; P < 0.001), male (28% vs 18%; P = 0.03), and have higher anxiety levels than those recruited by wait-room recruiters (P < 0.0001).
Conclusions
EMR systems prompting clinicians to refer patients with specific characteristics are an efficient recruitment tool with critical implications for increasing minority participation in clinical research.
doi:10.1007/s11606-007-0449-0
PMCID: PMC2359503  PMID: 18373143
electronic medical records; primary care; clinical trials; recruitment; anxiety disorders
21.  Arduous implementation: Does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice 
Background
Decision support technologies (DSTs, also known as decision aids) help patients and professionals take part in collaborative decision-making processes. Trials have shown favorable impacts on patient knowledge, satisfaction, decisional conflict and confidence. However, they have not become routinely embedded in health care settings. Few studies have approached this issue using a theoretical framework. We explained problems of implementing DSTs using the Normalization Process Model, a conceptual model that focuses attention on how complex interventions become routinely embedded in practice.
Methods
The Normalization Process Model was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment we applied the model and its main concepts to examine: the 'workability' of DSTs in professional-patient interactions; how DSTs affect knowledge relations between their users; how DSTs impact on users' skills and performance; and the impact of DSTs on the allocation of organizational resources.
Results
A conceptual analysis using the Normalization Process Model provided insight on implementation problems for DSTs in routine settings. Current research focuses mainly on the interactional workability of these technologies, but factors related to divisions of labor and health care, and the organizational contexts in which DSTs are used, are poorly described and understood.
Conclusion
The model successfully provided a framework for helping to identify factors that promote and inhibit the implementation of DSTs in healthcare and gave us insights into factors influencing the introduction of new technologies into contexts where negotiations are characterized by asymmetries of power and knowledge. Future research and development on the deployment of DSTs needs to take a more holistic approach and give emphasis to the structural conditions and social norms in which these technologies are enacted.
doi:10.1186/1748-5908-3-57
PMCID: PMC2631595  PMID: 19117509
22.  Barriers and Facilitators to Evidence-based Blood Pressure Control in Community Practice 
Journal of the American Board of Family Medicine : JABFM  2013;26(5):10.3122/jabfm.2013.05.130060.
Introduction
The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation.
Methods
Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR).
Results
Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the intervention’s perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme.
Conclusion
A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.
doi:10.3122/jabfm.2013.05.130060
PMCID: PMC3882900  PMID: 24004706
Evidence-based Medicine; Community Medicine; Home Blood Pressure Monitoring; Primary Health Care; Qualitative Research
23.  Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation 
Background
Tailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.
Methods
An ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically.
Results
Our ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations.
Conclusion
As tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.
doi:10.1186/1472-6963-7-125
PMCID: PMC1959520  PMID: 17683627
24.  Improving the management of people with a family history of breast cancer in primary care: before and after study of audit-based education 
BMC Family Practice  2013;14:105.
Background
In England, guidance from National Institute for Clinical Excellence (NICE) states women with a family history of breast cancer presenting to primary care should be reassured or referred.
We reviewed the evidence for interventions that might be applied in primary care and conducted an audit of whether low risk women are correctly advised and flagged.
Methods
We conducted a literature review to identify modifiable risk factors. We extracted routinely collected data from the computerised medical record systems of 6 general practices (population approximately 30,000); of the variables identified in the guidance. We implemented a quality improvement (QI) intervention called audit-based education (ABE) comparing participant practices with guidelines and each other before and after; we report odds ratios (OR) of any change in data recording.
Results
The review revealed evidence for advising on: diet, weight control, physical exercise, and alcohol. The proportion of patients with recordings of family history of: disease, neoplasms, and breast cancer were: 39.3%, 5.1% and 1.3% respectively. There was no significant change in the recording of family history of disease or cancer; OR 1.02 (95% CI 0.98-1.06); and 1.08 (95% CI 0.99-1.17) respectively. Recording of alcohol consumption and smoking both increased significantly; OR 1.36 (95% CI 1.30-1.43); and 1.42 (95% CI 1.27-1.60) respectively. Recording lifestyle advice fell; OR 0.84 (95% CI 0.81-0.88).
Conclusions
The study informs about current data recording and willingness to engage in ABE. Recording of risk factors improved after the intervention. Further QI is needed to achieve adherence to current guidance.
doi:10.1186/1471-2296-14-105
PMCID: PMC3734209  PMID: 23879178
25.  REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol 
Background
The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology—Participatory Learning and Action—to investigate and support implementation of such guidelines and training initiatives in routine practice.
Methods
This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders—migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory’s four constructs—coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings.
Discussion
This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.
doi:10.1186/1748-5908-7-111
PMCID: PMC3541149  PMID: 23167911

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