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1.  Interventions for promoting information and communication technologies adoption in healthcare professionals 
Background
Information and communication technologies (ICT) are defined as digital and analogue technologies that facilitate the capturing, processing, storage and exchange of information via electronic communication. ICTs have the potential to improve information management, access to health services, quality of care, continuity of services, and cost containment. Knowledge is lacking on conditions for successful ICT integration into practice.
Objectives
To carry out a systematic review of the effectiveness of interventions to promote the adoption of ICT by healthcare professionals.
Search methods
Specific strategies, defined with the help of an information specialist, were used to search the Cochrane Effective Practice and Organisation of Care Group (EPOC) register and additional relevant databases. We considered studies published from January 1990 until October 2007.
Selection criteria
Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before/after studies (CBAs), and interrupted time series (ITS) that reported objectively measured outcomes concerning the effect of interventions to promote adoption of ICT in healthcare professionals’ practices.
Data collection and analysis
Two reviewers independently assessed each potentially relevant study for inclusion. We resolved discrepancies by discussion or a third reviewer. Two teams of two reviewers independently extracted data and assessed the quality of included studies. A meta-analysis of study outcomes was not possible, given the small number of included studies and the heterogeneity of intervention and outcomes measures. We conducted qualitative analyses, and have presented the results in a narrative format.
Main results
Ten studies met the inclusion criteria. Nine of them were RCTs. All studies involved physicians as participants (including postgraduate trainees), and one study also included other participants. Only two studies measured patient outcomes. Searching skills and/or frequency of use of electronic databases, mainly MEDLINE, were targeted in eight studies. Use of Internet for audit and feedback, and email for provider-patient communication, were targeted in two studies. Four studies showed small to moderate positive effects of the intervention on ICT adoption. Four studies were unable to demonstrate significant positive effects, and the two others showed mixed effects. No studies looked at the long-term effect or sustainability of the intervention.
Authors’ conclusions
There is very limited evidence on effective interventions promoting the adoption of ICTs by healthcare professionals. Small effects have been reported for interventions targeting the use of electronic databases and digital libraries. The effectiveness of interventions to promote ICT adoption in healthcare settings remains uncertain, and more well designed trials are needed.
doi:10.1002/14651858.CD006093.pub2
PMCID: PMC3973635  PMID: 19160265 CAMSID: cams377
Databases, Bibliographic [utilization]; Health Personnel [*statistics & numerical data]; Information Storage and Retrieval [*utilization]; Professional Practice [*statistics & numerical data]; Randomized Controlled Trials as Topic
2.  Development of a Simple 12-Item Theory-Based Instrument to Assess the Impact of Continuing Professional Development on Clinical Behavioral Intentions 
PLoS ONE  2014;9(3):e91013.
Background
Decision-makers in organizations providing continuing professional development (CPD) have identified the need for routine assessment of its impact on practice. We sought to develop a theory-based instrument for evaluating the impact of CPD activities on health professionals' clinical behavioral intentions.
Methods and Findings
Our multipronged study had four phases. 1) We systematically reviewed the literature for instruments that used socio-cognitive theories to assess healthcare professionals' clinically-oriented behavioral intentions and/or behaviors; we extracted items relating to the theoretical constructs of an integrated model of healthcare professionals' behaviors and removed duplicates. 2) A committee of researchers and CPD decision-makers selected a pool of items relevant to CPD. 3) An international group of experts (n = 70) reached consensus on the most relevant items using electronic Delphi surveys. 4) We created a preliminary instrument with the items found most relevant and assessed its factorial validity, internal consistency and reliability (weighted kappa) over a two-week period among 138 physicians attending a CPD activity. Out of 72 potentially relevant instruments, 47 were analyzed. Of the 1218 items extracted from these, 16% were discarded as improperly phrased and 70% discarded as duplicates. Mapping the remaining items onto the constructs of the integrated model of healthcare professionals' behaviors yielded a minimum of 18 and a maximum of 275 items per construct. The partnership committee retained 61 items covering all seven constructs. Two iterations of the Delphi process produced consensus on a provisional 40-item questionnaire. Exploratory factorial analysis following test-retest resulted in a 12-item questionnaire. Cronbach's coefficients for the constructs varied from 0.77 to 0.85.
Conclusion
A 12-item theory-based instrument for assessing the impact of CPD activities on health professionals' clinical behavioral intentions showed adequate validity and reliability. Further studies could assess its responsiveness to behavior change following CPD activities and its capacity to predict health professionals' clinical performance.
doi:10.1371/journal.pone.0091013
PMCID: PMC3958345  PMID: 24643173
3.  Development and Content Validation of the Information Assessment Method for Patients and Consumers 
JMIR Research Protocols  2014;3(1):e7.
Background
Online consumer health information addresses health problems, self-care, disease prevention, and health care services and is intended for the general public. Using this information, people can improve their knowledge, participation in health decision-making, and health. However, there are no comprehensive instruments to evaluate the value of health information from a consumer perspective.
Objective
We collaborated with information providers to develop and validate the Information Assessment Method for all (IAM4all) that can be used to collect feedback from information consumers (including patients), and to enable a two-way knowledge translation between information providers and consumers.
Methods
Content validation steps were followed to develop the IAM4all questionnaire. The first version was based on a theoretical framework from information science, a critical literature review and prior work. Then, 16 laypersons were interviewed on their experience with online health information and specifically their impression of the IAM4all questionnaire. Based on the summaries and interpretations of interviews, questionnaire items were revised, added, and excluded, thus creating the second version of the questionnaire. Subsequently, a panel of 12 information specialists and 8 health researchers participated in an online survey to rate each questionnaire item for relevance, clarity, representativeness, and specificity. The result of this expert panel contributed to the third, current, version of the questionnaire.
Results
The current version of the IAM4all questionnaire is structured by four levels of outcomes of information seeking/receiving: situational relevance, cognitive impact, information use, and health benefits. Following the interviews and the expert panel survey, 9 questionnaire items were confirmed as relevant, clear, representative, and specific. To improve readability and accessibility for users with a lower level of literacy, 19 items were reworded and all inconsistencies in using a passive or active voice have been solved. One item was removed due to redundancy. The current version of the IAM4all questionnaire contains 28 items.
Conclusions
We developed and content validated the IAM4all in partnership with information providers, information specialists, researchers and representatives of information consumers. This questionnaire can be integrated within electronic knowledge resources to stimulate users’ reflection (eg, their intention to use information). We claim that any organization (eg, publishers, community organizations, or patient associations), can evaluate and improve their online consumer health information from a consumers’ perspective using this method.
doi:10.2196/resprot.2908
PMCID: PMC3958673  PMID: 24550180
information use; information retrieval; push technology; consumer health information; consumer-centered outcomes; content validity
4.  Core Competencies for Shared Decision Making Training Programs: Insights From an International, Interdisciplinary Working Group 
Shared decision making is now making inroads in health care professionals’ continuing education curriculum, but there is no consensus on what core competencies are required by clinicians for effectively involving patients in health-related decisions. Ready-made programs for training clinicians in shared decision making are in high demand, but existing programs vary widely in their theoretical foundations, length, and content. An international, interdisciplinary group of 25 individuals met in 2012 to discuss theoretical approaches to making health-related decisions, compare notes on existing programs, take stock of stakeholders concerns, and deliberate on core competencies. This article summarizes the results of those discussions. Some participants believed that existing models already provide a sufficient conceptual basis for developing and implementing shared decision making competency-based training programs on a wide scale. Others argued that this would be premature as there is still no consensus on the definition of shared decision making or sufficient evidence to recommend specific competencies for implementing shared decision making. However, all participants agreed that there were 2 broad types of competencies that clinicians need for implementing shared decision making: relational competencies and risk communication competencies. Further multidisciplinary research could broaden and deepen our understanding of core competencies for shared decision making training.
doi:10.1002/chp.21197
PMCID: PMC3911960  PMID: 24347105 CAMSID: cams3819
shared decision making; education; patient-centered care; implementation science; theory; risk communication
5.  Impact of DECISION + 2 on patient and physician assessment of shared decision making implementation in the context of antibiotics use for acute respiratory infections 
Background
DECISION + 2, a training program for physicians, is designed to implement shared decision making (SDM) in the context of antibiotics use for acute respiratory tract infections (ARTIs). We evaluated the impact of DECISION + 2 on SDM implementation as assessed by patients and physicians, and on physicians’ intention to engage in SDM.
Methods
From 2010 to 2011, a multi-center, two-arm, parallel randomized clustered trial appraised the effects of DECISION + 2 on the decision to use antibiotics for patients consulting for ARTIs. We randomized 12 family practice teaching units (FPTUs) to either DECISION + 2 or usual care. After the consultation, both physicians and patients independently completed questionnaires based on the D-Option scale regarding SDM behaviors during the consultation. Patients also answered items assessing the role they assumed during the consultation (active/collaborative/passive). Before and after the intervention, physicians completed a questionnaire based on the Theory of Planned Behavior to measure their intention to engage in SDM. To account for the cluster design, we used generalized estimating equations and generalized linear mixed models to assess the impact of DECISION + 2 on the outcomes of interest.
Results
A total of 270 physicians (66% women) participated in the study. After DECISION + 2, patients’ D-Option scores were 80.1 ± 1.1 out of 100 in the intervention group and 74.9 ± 1.1 in the control group (p = 0.001). Physicians’ D-Option scores were 79.7 ± 1.8 in the intervention group and 76.3 ± 1.9 in the control group (p = 0.2). However, subgroup analyses showed that teacher physicians D-Option scores were 79.7 ± 1.5 and 73.0 ± 1.4 respectively (p = 0.001). More patients reported assuming an active or collaborative role in the intervention group (67.1%), than in the control group (49.2%) (p = 0.04). There was a significant relation between patients’ and physicians’ D-Option scores (p < 0.01) and also between patient-reported assumed roles and both D-Option scores (as assessed by patients, p < 0.01; and physicians, p = 0.01). DECISION + 2 had no impact on the intention of physicians to engage in SDM.
Conclusion
DECISION + 2 positively influenced SDM behaviors as assessed by patients and teacher physicians. Physicians’ intention to engage in SDM was not affected by DECISION + 2.
Trial registration
ClinicalTrials.gov trials register no. NCT01116076.
doi:10.1186/1748-5908-8-144
PMCID: PMC3879432  PMID: 24369771
Shared decision making; Implementation; Theory of planned behavior; Training
6.  Wikis and Collaborative Writing Applications in Health Care: A Scoping Review 
Background
Collaborative writing applications (eg, wikis and Google Documents) hold the potential to improve the use of evidence in both public health and health care. The rapid rise in their use has created the need for a systematic synthesis of the evidence of their impact as knowledge translation (KT) tools in the health care sector and for an inventory of the factors that affect their use.
Objective
Through the Levac six-stage methodology, a scoping review was undertaken to explore the depth and breadth of evidence about the effective, safe, and ethical use of wikis and collaborative writing applications (CWAs) in health care.
Methods
Multiple strategies were used to locate studies. Seven scientific databases and 6 grey literature sources were queried for articles on wikis and CWAs published between 2001 and September 16, 2011. In total, 4436 citations and 1921 grey literature items were screened. Two reviewers independently reviewed citations, selected eligible studies, and extracted data using a standardized form. We included any paper presenting qualitative or quantitative empirical evidence concerning health care and CWAs. We defined a CWA as any technology that enables the joint and simultaneous editing of a webpage or an online document by many end users. We performed qualitative content analysis to identify the factors that affect the use of CWAs using the Gagnon framework and their effects on health care using the Donabedian framework.
Results
Of the 111 studies included, 4 were experimental, 5 quasi-experimental, 5 observational, 52 case studies, 23 surveys about wiki use, and 22 descriptive studies about the quality of information in wikis. We classified them by theme: patterns of use of CWAs (n=26), quality of information in existing CWAs (n=25), and CWAs as KT tools (n=73). A high prevalence of CWA use (ie, more than 50%) is reported in 58% (7/12) of surveys conducted with health care professionals and students. However, we found only one longitudinal study showing that CWA use is increasing in health care. Moreover, contribution rates remain low and the quality of information contained in different CWAs needs improvement. We identified 48 barriers and 91 facilitators in 4 major themes (factors related to the CWA, users’ knowledge and attitude towards CWAs, human environment, and organizational environment). We also found 57 positive and 23 negative effects that we classified into processes and outcomes.
Conclusions
Although we found some experimental and quasi-experimental studies of the effectiveness and safety of CWAs as educational and KT interventions, the vast majority of included studies were observational case studies about CWAs being used by health professionals and patients. More primary research is needed to find ways to address the different barriers to their use and to make these applications more useful for different stakeholders.
doi:10.2196/jmir.2787
PMCID: PMC3929050  PMID: 24103318
collaborative writing applications; collaborative authoring; knowledge management; crowdsourcing; medical informatics; ehealth; Internet; Wiki; Wikipedia; Google Docs; Google Knol; Web 2.0; knowledge translation; evidence-based medicine; participatory med
7.  Decision making in family medicine 
Canadian Family Physician  2013;59(10):1084-1094.
Abstract
Objective
To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process.
Design
Randomized trial.
Setting
Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que.
Participants
Fifteen second-year family medicine residents.
Intervention
Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database.
Main outcome measures
The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine’s effect on the decision-making process in clinical practice.
Results
Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either search engine. The mean (SD) time of the initial search for each question was 23.5 (7.6) minutes with InfoClinique and 22.3 (7.8) minutes with the Trip database (P = .30). Participants’ perceptions of each engine’s effect on the decision-making process were very positive and similar for both search engines.
Conclusion
Family medicine residents’ ability to provide correct answers to clinical questions increased dramatically and similarly with the use of both InfoClinique and the Trip database. These tools have strong potential to increase the quality of medical care.
PMCID: PMC3796978  PMID: 24130286
8.  Use and teaching of pneumatic otoscopy in a family medicine residency program 
Canadian Family Physician  2013;59(9):972-979.
Abstract
Objective
To determine to what extent FPs teach and use pneumatic otoscopy and to identify the chief influences on this behaviour.
Design
Mixed-methods descriptive study conducted between March and May 2011.
Setting
The family medicine residency program at Laval University in Quebec city, Que.
Participants
Directors of the family medicine teaching units (FMTUs), teachers, and residents.
Methods
We used questionnaires to assess the availability of pneumatic otoscopy equipment in 12 FMTUs, current behaviour and behavioural intention among physicians (residents and teachers) to use or teach pneumatic otoscopy, and facilitators and barriers to these practices. We also conducted 2 focus groups to further explore the facilitators of and barriers to using pneumatic otoscopy. We used descriptive statistics for quantitative data, transcribed the qualitative material, and performed content analysis.
Main findings
Eight of the 12 FMTUs reported having pneumatic otoscopy equipment. Four had it in all of their consulting rooms, and 2 formally taught it. Nine (4%) of 211 physicians reported regular use of pneumatic otoscopy. Mean (SD) intention to teach or use pneumatic otoscopy during the next year was low (2.4 [1.0] out of 5). Teachers identified improved diagnostic accuracy as the main facilitator both for use and for teaching, while residents identified recommendation by practice guidelines as the main facilitator for use. All physicians reported lack of availability of equipment as the main barrier to use. The main barrier to teaching pneumatic otoscopy reported by teachers was that they did not use it themselves. In focus groups, themes of consequences, capabilities, and socioprofessional influences were most dominant. Residents clearly identified role modeling by teachers as facilitating the use of pneumatic otoscopy.
Conclusion
Pneumatic otoscopy is minimally used and taught in the family medicine residency program studied. Interventions to increase its use should target identified underlying beliefs and facilitators of and barriers to its use and teaching.
PMCID: PMC3771728  PMID: 24029515
9.  Psychosocial Factors of Dietitians' Intentions to Adopt Shared Decision Making Behaviours: A Cross-Sectional Survey 
PLoS ONE  2013;8(5):e64523.
Objectives
While shared decision making (SDM) promotes health-related decisions that are informed, value-based and adhered to, few studies report on theory-based approaches to SDM adoption by healthcare professionals. We aimed to identify the factors influencing dietitians' intentions to adopt two SDM behaviours: 1) present dietary treatment options to patients and 2) help patients clarify their values and preferences.
Methods
We conducted a cross-sectional postal survey based on the Theory of Planned Behaviour among 428 randomly selected dietitians working in clinical practice across the Province of Quebec, Canada. We performed descriptive analyses and multiple regression analyses to determine the variables that explained the variance in intention to perform the behaviours.
Results
A total of 203 dietitians completed the questionnaire. Their ages were from 23 to 66 and they had been practising dietetics for 15.4±11.1 years (mean ± SD). On a scale from 1 to 7 (from strongly disagree to strongly agree), dietitians' intentions to present dietary treatment options and to clarify their patients' values and preferences were 5.00±1.14 and 5.68±0.74, respectively. Perceived behavioural control (β = 0.56, ρ<0.0001), subjective norm (β = 0.16, ρ<0.05), and moral norm (β = 0.22, ρ<0.0001), were the factors significantly predicting the intention to present dietary treatment options, while perceived behavioural control (β = 0.60, ρ<0.0001), attitude (β = 0.20, ρ<0.05), and professional norm (β = 0.22, ρ<0.001), significantly predicted the intention to help patients' clarify their values and preferences.
Conclusion
Our results showed that dietitians intend to adopt the two SDM behaviours studied. Factors influencing intention were different for each behaviour, except for perceived behavioural control which was common to both behaviours. Thus, perceived behavioural control could be a key factor in interventions aiming to encourage implementation of SDM by dietitians.
doi:10.1371/journal.pone.0064523
PMCID: PMC3659101  PMID: 23700484
10.  Shared Decision Making Does Not Influence Physicians against Clinical Practice Guidelines 
PLoS ONE  2013;8(4):e62537.
Background
While shared decision making (SDM) and adherence to clinical practice guidelines (CPGs) are important, some believe they are incompatible. This study explored the mutual influence between physicians’ intention to engage in SDM and their intention to follow CPGs.
Methods
Embedded within a clustered randomized trial to assess the impact of training physicians in SDM about using antibiotics to treat acute respiratory tract infections, this study evaluated physicians’ intentions to both engage in SDM and follow CPGs. A self-administered questionnaire based on the theory of planned behavior evaluated both behavioral intentions and their respective determinants (attitude, subjective norm and perceived behavioral control) at study entry and exit. We used path analysis to explore the relationships between the intentions. We conducted statistical analyses using the maximum likelihood method and the variance-covariance matrix. Goodness of fit indices encompassed the chi-square statistic, the comparative fit index and the root mean square error of approximation.
Results
We analyzed 244 responses at entry and 236 at exit. In the control group, at entry we observed that physicians’ intention to engage in SDM (r = 0, t = 0.03) did not affect their intention to follow CPGs; however, their intention to follow CPGs (r = −0.31 t = −2.82) did negatively influence their intention to engage in SDM. At exit, neither behavioral intention influenced the other. In the experimental group, at entry neither behavioral intention influenced the other; at exit, the intention to engage in SDM still did not influence the intention to use CPGs, although the intention to follow CPGs (r = −0.15 t = −2.02) slightly negatively influenced the intention to engage in SDM, but this was not clinically significant.
Conclusion
Physicians’ intention to engage in SDM does not affect their intention to adopt CPGs even after SDM training. Physicians’ intention to adopt CPGs had no clinically significant influence on intention to engage in SDM.
Trial Registration
ClinicalTrials.gov NCT01116076
doi:10.1371/journal.pone.0062537
PMCID: PMC3634782  PMID: 23638111
11.  Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial 
Background:
Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on the percentage of patients who decided to take antibiotics after consultation with a physician or resident.
Methods:
We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients’ perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients’ adherence to the decision, repeat consultation, decisional regret and quality of life.
Results:
We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34–0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups.
Interpretation:
The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation.
ClinicalTrials.gov trial register no. NCT01116076.
doi:10.1503/cmaj.120568
PMCID: PMC3447039  PMID: 22847969
12.  Users’ perspectives of key factors to implementing electronic health records in Canada: a Delphi study 
Background
Interoperable electronic health record (EHR) solutions are currently being implemented in Canada, as in many other countries. Understanding EHR users’ perspectives is key to the success of EHR implementation projects. This Delphi study aimed to assess in the Canadian context the applicability, the importance, and the priority of pre-identified factors from a previous mixed-methods systematic review of international literature.
Methods
A three-round Delphi study was held with representatives of 4 Canadian EHR user groups defined as partners of the implementation process who use or are expected to use EHR in their everyday activity. These groups are: non-physician healthcare professionals, health information professionals, managers, and physicians. Four bilingual online questionnaire versions were developed from factors identified by the systematic review. Participants were asked to rate the applicability and the importance of each factor. The main outcome measures were consensus and priority. Consensus was defined a priori as strong (≥ 75%) or moderate (≥ 60-74%) according to user groups’ level of agreement on applicability and importance, partial (≥ 60%) when participants agreed only on applicability or importance, or as no consensus (< 60%). Priority for decision-making was defined as factors with strong consensus with scores of 4 or 5 on a five-point Likert scale for applicability and importance.
Results
Three Delphi rounds were completed by 64 participants. Levels of consensus of 100%, 64%, 64%, and 44% were attained on factors submitted to non-physician healthcare professionals, health information professionals, managers, and physicians, respectively. While agreement between and within user groups varied, key factors were prioritized if they were classified as strong (≥ 75% from questionnaire answers of user groups), for decision-making concerning EHR implementation. The10 factors that were prioritized are perceived usefulness, productivity, motivation, participation of end-users in the implementation strategy, patient and health professional interaction, lack of time and workload, resources availability, management, outcome expectancy, and interoperability.
Conclusions
Amongst all factors influencing EHR implementation identified in a previous systematic review, ten were prioritized through this Delphi study. The varying levels of agreement between and within user groups could mean that users’ perspectives of each factor are complex and that each user group has unique professional priorities and roles in the EHR implementation process. As more EHR implementations in Canada are completed it will be possible to corroborate this preliminary result with a larger population of EHR users.
doi:10.1186/1472-6947-12-105
PMCID: PMC3470948  PMID: 22967231
Delphi technique; Adoption factors; Implementation factors; Electronic health record; Health information technology; Health communication technology; Medical informatics
13.  Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decisionmaking: a study protocol 
Background
Decision Boxes are summaries of the most important benefits and harms of health interventions provided to clinicians before they meet the patient, to prepare them to help patients make informed and value-based decisions. Our objective is to explore the barriers and facilitators to using Decision Boxes in clinical practice, more precisely factors stemming from (1) the Decision Boxes themselves, (2) the primary healthcare team (PHT), and (3) the primary care practice environment.
Methods/design
A two-phase mixed methods study will be conducted. Eight Decision Boxes relevant to primary care, and written in both English and in French, will be hosted on a website together with a tutorial to introduce the Decision Box. The Decision Boxes will be delivered as weekly emails over a span of eight weeks to clinicians of PHTs (family physicians, residents and nurses) in five primary care clinics located across two Canadian provinces. Using a web-questionnaire, clinicians will rate each Decision Box with the Information Assessment Method (cognitive impacts, relevance, usefulness, expected benefits) and with a questionnaire based on the Theory of Planned Behavior to study the determinants of clinicians’ intention to use what they learned from that Decision Box in their patient encounter (attitude, social norm, perceived behavioral control). Web-log data will be used to monitor clinicians’ access to the website. Following the 8-week intervention, we will conduct semi-structured group interviews with clinicians and individual interviews with clinic administrators to explore contextual factors influencing the use of the Decision Boxes. Data collected from questionnaires, focus groups and individual interviews will be combined to identify factors potentially influencing implementation of Decision Boxes in clinical practice by clinicians of PHTs.
Conclusions
This project will allow tailoring of Decision Boxes and their delivery to overcome the specific barriers identified by clinicians of PHTs to improve the implementation of shared decision making in this setting.
doi:10.1186/1472-6947-12-85
PMCID: PMC3472191  PMID: 22867107
(3–10); Evidence-based practice; Continuing professional education; Risk communication; Patient-centered care; Counselling; Clinical topic summary; Decision support; Knowledge translation; Implementation science
14.  Decision boxes for clinicians to support evidence-based practice and shared decision making: the user experience 
Background
This project engages patients and physicians in the development of Decision Boxes, short clinical topic summaries covering medical questions that have no single best answer. Decision Boxes aim to prepare the clinician to communicate the risks and benefits of the available options to the patient so they can make an informed decision together.
Methods
Seven researchers (including four practicing family physicians) selected 10 clinical topics relevant to primary care practice through a Delphi survey. We then developed two one-page prototypes on two of these topics: prostate cancer screening with the prostate-specific antigen test, and prenatal screening for trisomy 21 with the serum integrated test. We presented the prototypes to purposeful samples of family physicians distributed in two focus groups, and patients distributed in four focus groups. We used the User Experience Honeycomb to explore barriers and facilitators to the communication design used in Decision Boxes. All discussions were transcribed, and three researchers proceeded to thematic content analysis of the transcriptions. The coding scheme was first developed from the Honeycomb’s seven themes (valuable, usable, credible, useful, desirable, accessible, and findable), and included new themes suggested by the data. Prototypes were modified in light of our findings.
Results
Three rounds were necessary for a majority of researchers to select 10 clinical topics. Fifteen physicians and 33 patients participated in the focus groups. Following analyses, three sections were added to the Decision Boxes: introduction, patient counseling, and references. The information was spread to two pages to try to make the Decision Boxes less busy and improve users’ first impression. To try to improve credibility, we gave more visibility to the research institutions involved in development. A statement on the boxes’ purpose and a flow chart representing the shared decision-making process were added with the intent of clarifying the tool’s purpose. Information about the risks and benefits according to risk levels was added to the Decision Boxes, to try to ease the adaptation of the information to individual patients.
Conclusion
Results will guide the development of the eight remaining Decision Boxes. A future study will evaluate the effect of Decision Boxes on the integration of evidence-based and shared decision making principles in clinical practice.
doi:10.1186/1748-5908-7-72
PMCID: PMC3533695  PMID: 22862935
Evidence-based medicine; User experience; Risk communication; Usability; Patient-centered care; Counselling; Clinical topic summary; Decision support; Knowledge translation; Communication design
15.  The Impact of Physicians’ Reactions to Uncertainty on Patients’ Decision Satisfaction 
Rationale
Patients’ and physicians’ response to uncertainty may affect decision outcomes. The purpose of this study was to explore the impact of patients’ and physicians’ reactions to uncertainty on patients’ satisfaction with breast health decisions.
Method
Seventy-five women facing breast cancer prevention or treatment decisions and five surgeons were recruited from a Breast Health Center. Patients’ and physicians’ anxiety from uncertainty was assessed using the Physicians’ Reactions to Uncertainty Scale; wording was slightly modified for patients to ensure the scale was applicable. Patients’ decision satisfaction was assessed 1–2 weeks after their appointment. A mixed-effects logistic regression model was used to assess associations between patients’ and providers’ anxiety from uncertainty and patients’ decision satisfaction. A provider-specific random effects term was included in the model to account for correlation among patients treated by the same provider.
Results
Patients’ decision satisfaction was associated with physicians’ anxiety from uncertainty (beta = 0.92, p<0.01), but not with patients’ anxiety from uncertainty (beta = −0.18, p>0.27).
Conclusions
This study suggests that physicians’ reactions to uncertainty may have an effect on decision satisfaction in patients. More research is needed to confirm this relationship and to determine how to help patient-provider dyads to manage the uncertainty that is inherent in most cancer decisions.
doi:10.1111/j.1365-2753.2010.01520.x
PMCID: PMC2978752  PMID: 20695949
Shared Decision Making; Reactions to Uncertainty
18.  Health Care Professionals’ Beliefs About Using Wiki-Based Reminders to Promote Best Practices in Trauma Care 
Background
Wikis are knowledge translation tools that could help health professionals implement best practices in acute care. Little is known about the factors influencing professionals’ use of wikis.
Objectives
To identify and compare the beliefs of emergency physicians (EPs) and allied health professionals (AHPs) about using a wiki-based reminder that promotes evidence-based care for traumatic brain injuries.
Methods
Drawing on the theory of planned behavior, we conducted semistructured interviews to elicit EPs’ and AHPs’ beliefs about using a wiki-based reminder. Previous studies suggested a sample of 25 EPs and 25 AHPs. We purposefully selected participants from three trauma centers in Quebec, Canada, to obtain a representative sample. Using univariate analyses, we assessed whether our participants’ gender, age, and level of experience were similar to those of all eligible individuals. Participants viewed a video showing a clinician using a wiki-based reminder, and we interviewed participants about their behavioral, control, and normative beliefs—that is, what they saw as advantages, disadvantages, barriers, and facilitators to their use of a reminder, and how they felt important referents would perceive their use of a reminder. Two reviewers independently analyzed the content of the interview transcripts. We considered the 75% most frequently mentioned beliefs as salient. We retained some less frequently mentioned beliefs as well.
Results
Of 66 eligible EPs and 444 eligible AHPs, we invited 55 EPs and 39 AHPs to participate, and 25 EPs and 25 AHPs (15 nurses, 7 respiratory therapists, and 3 pharmacists) accepted. Participating AHPs had more experience than eligible AHPs (mean 14 vs 11 years; P = .04). We noted no other significant differences. Among EPs, the most frequently reported advantage of using a wiki-based reminder was that it refreshes the memory (n = 14); among AHPs, it was that it provides rapid access to protocols (n = 16). Only 2 EPs mentioned a disadvantage (the wiki added stress). The most frequently reported favorable referent was nurses for EPs (n = 16) and EPs for AHPs (n = 19). The most frequently reported unfavorable referents were people resistant to standardized care for EPs (n = 8) and people less comfortable with computers for AHPs (n = 11). The most frequent facilitator for EPs was ease of use (n = 19); for AHPs, it was having a bedside computer (n = 20). EPs’ most frequently reported barrier was irregularly updated wiki-based reminders (n = 18); AHPs’ was undetermined legal responsibility (n = 10).
Conclusions
We identified EPs’ and AHPs’ salient beliefs about using a wiki-based reminder. We will draw on these beliefs to construct a questionnaire to measure the importance of these determinants to EPs’ and AHPs’ intention to use a wiki-based reminder promoting evidence-based care for traumatic brain injuries.
doi:10.2196/jmir.1983
PMCID: PMC3376518  PMID: 22515985
Wiki; Collaborative writing applications; Web 2.0; traumatic brain injury; interprofessional collaboration; reminders; computerized clinical decision-support system; knowledge translation; evidence-based medicine; theory of planned behavior
19.  Wikis and Collaborative Writing Applications in Health Care: A Scoping Review Protocol 
JMIR Research Protocols  2012;1(1):e1.
The rapid rise in the use of collaborative writing applications (eg, wikis, Google Documents, and Google Knol) has created the need for a systematic synthesis of the evidence of their impact as knowledge translation (KT) tools in the health care sector and for an inventory of the factors that affect their use. While researchers have conducted systematic reviews on a range of software-based information and communication technologies as well as other social media (eg, virtual communities of practice, virtual peer-to-peer communities, and electronic support groups), none have reviewed collaborative writing applications in the medical sector. The overarching goal of this project is to explore the depth and breadth of evidence for the use of collaborative writing applications in health care. Thus, the purposes of this scoping review will be to (1) map the literature on collaborative writing applications; (2) compare the applications’ features; (3) describe the evidence of each application’s positive and negative effects as a KT intervention in health care; (4) inventory and describe the barriers and facilitators that affect the applications’ use; and (5) produce an action plan and a research agenda. A six-stage framework for scoping reviews will be used: (1) identifying the research question; (2) identifying relevant studies within the selected databases (using the EPPI-Reviewer software to classify the studies); (3) selecting studies (an iterative process in which two reviewers search the literature, refine the search strategy, and review articles for inclusion); (4) charting the data (using EPPI-Reviewer’s data-charting form); (5) collating, summarizing, and reporting the results (performing a descriptive, numerical, and interpretive synthesis); and (6) consulting knowledge users during three planned meetings. Since this scoping review concerns the use of collaborative writing applications as KT interventions in health care, we will use the Knowledge to Action (KTA) framework to describe and compare the various studies and collaborative writing projects we find. In addition to guiding the use of collaborative writing applications in health care, this scoping review will advance the science of KT by testing tools that could be used to evaluate other social media. We also expect to identify areas that require further systematic reviews and primary research and to produce a highly relevant research agenda that explores and leverages the potential of collaborative writing software. To date, this is the first study to use the KTA framework to study the role collaborative writing applications in KT, and the first to involve three national and international institutional knowledge users as part of the research process.
doi:10.2196/resprot.1993
PMCID: PMC3626140  PMID: 23612481
20.  Involving patients in HTA activities at local level: a study protocol based on the collaboration between researchers and knowledge users 
Background
The literature recognizes a need for greater patient involvement in health technology assessment (HTA), but few studies have been reported, especially at the local level. Following the decentralisation of HTA in Quebec, Canada, the last few years have seen the creation of HTA units in many Quebec university hospital centres. These units represent a unique opportunity for increased patient involvement in HTA at the local level. Our project will engage patients in an assessment being carried out by a local HTA team to assess alternatives to isolation and restraint for hospitalized or institutionalized adults. Our objectives are to: 1) validate a reference framework for exploring the relevance and applicability of various models of patient involvement in HTA, 2) implement strategies that involve patients (including close relatives and representatives) at different stages of the HTA process, 3) evaluate intervention processes, and 4) explore the impact of these interventions on a) the applicability and acceptability of recommendations arising from the assessment, b) patient satisfaction, and c) the sustainability of this approach in HTA.
Methods
For Objective 1, we will conduct individual interviews with various stakeholders affected by the use of alternatives to isolation and restraint for hospitalized or institutionalized adults. For Objective 2, we will implement three specific strategies for patient involvement in HTA: a) direct participation in the HTA process, b) consultation of patients or their close relatives through data collection, and c) patient involvement in the dissemination of HTA results. For Objectives 3 and 4, we will evaluate the intervention processes and the impact of patient involvement strategies on the recommendations arising from the HTA and the understanding of the ethical and social implications of the HTA.
Discussion
This project is likely to influence future HTA practices because it directly targets knowledge users' need for strategies that increase patient involvement in HTA. By documenting the processes and outcomes of these involvement strategies, the project will contribute to the knowledge base related to patient involvement in HTA.
doi:10.1186/1472-6963-12-14
PMCID: PMC3274445  PMID: 22248231
Health technology assessment; patient involvement; decision making; knowledge users; alternatives to isolation and restraint
21.  Core competencies in the science and practice of knowledge translation: description of a Canadian strategic training initiative 
Background
Globally, healthcare systems are attempting to optimize quality of care. This challenge has resulted in the development of implementation science or knowledge translation (KT) and the resulting need to build capacity in both the science and practice of KT.
Findings
We are attempting to meet these challenges through the creation of a national training initiative in KT. We have identified core competencies in this field and have developed a series of educational courses and materials for three training streams. We report the outline for this approach and the progress to date.
Conclusions
We have prepared a strategy to develop, implement, and evaluate a national training initiative to build capacity in the science and practice of KT. Ultimately through this initiative, we hope to meet the capacity demand for KT researchers and practitioners in Canada that will lead to improved care and a strengthened healthcare system.
doi:10.1186/1748-5908-6-127
PMCID: PMC3292943  PMID: 22152223
22.  Measuring organizational readiness for knowledge translation in chronic care 
Background
Knowledge translation (KT) is an imperative in order to implement research-based and contextualized practices that can answer the numerous challenges of complex health problems. The Chronic Care Model (CCM) provides a conceptual framework to guide the implementation process in chronic care. Yet, organizations aiming to improve chronic care require an adequate level of organizational readiness (OR) for KT. Available instruments on organizational readiness for change (ORC) have shown limited validity, and are not tailored or adapted to specific phases of the knowledge-to-action (KTA) process. We aim to develop an evidence-based, comprehensive, and valid instrument to measure OR for KT in healthcare. The OR for KT instrument will be based on core concepts retrieved from existing literature and validated by a Delphi study. We will specifically test the instrument in chronic care that is of an increasing importance for the health system.
Methods
Phase one: We will conduct a systematic review of the theories and instruments assessing ORC in healthcare. The retained theoretical information will be synthesized in a conceptual map. A bibliography and database of ORC instruments will be prepared after appraisal of their psychometric properties according to the standards for educational and psychological testing. An online Delphi study will be carried out among decision makers and knowledge users across Canada to assess the importance of these concepts and measures at different steps in the KTA process in chronic care.
Phase two: A final OR for KT instrument will be developed and validated both in French and in English and tested in chronic disease management to measure OR for KT regarding the adoption of comprehensive, patient-centered, and system-based CCMs.
Discussion
This study provides a comprehensive synthesis of current knowledge on explanatory models and instruments assessing OR for KT. Moreover, this project aims to create more consensus on the theoretical underpinnings and the instrumentation of OR for KT in chronic care. The final product--a comprehensive and valid OR for KT instrument--will provide the chronic care settings with an instrument to assess their readiness to implement evidence-based chronic care.
doi:10.1186/1748-5908-6-72
PMCID: PMC3158542  PMID: 21752264
23.  How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration 
Background
Shared decision-making is not widely implemented in healthcare. We aimed to set a research agenda about promoting shared decision-making through continuing professional development.
Methods
Thirty-six participants met for two days.
Results
Participants suggested ways to improve an environmental scan that had inventoried 53 shared decision-making training programs from 14 countries. Their proposed research agenda included reaching an international consensus on shared decision-making competencies and creating a framework for accrediting continuing professional development initiatives in shared decision-making.
Conclusions
Variability in shared decision-making training programs showcases the need for quality assurance frameworks.
doi:10.1186/1748-5908-6-68
PMCID: PMC3154854  PMID: 21729310
24.  Exploring dietitians' salient beliefs about shared decision-making behaviors 
Background
Shared decision making (SDM), a process by which health professionals and patients go through the decision-making process together to agree on treatment, is a promising strategy for promoting diet-related decisions that are informed and value based and to which patients adhere well. The objective of the present study was to identify dietitians' salient beliefs regarding their exercise of two behaviors during the clinical encounter, both of which have been deemed essential for SDM to take place: (1) presenting patients with all dietary treatment options for a given health condition and (2) helping patients clarify their values and preferences regarding the options.
Methods
Twenty-one dietitians were allocated to four focus groups. Facilitators conducted the focus groups using a semistructured interview guide based on the Theory of Planned Behavior. Discussions were audiotaped, transcribed verbatim, coded, and analyzed with NVivo8 (QSR International, Cambridge, MA) software.
Results
Most participants stated that better patient adherence to treatment was an advantage of adopting the two SDM behaviors. Dietitians identified patients, physicians, and the multidisciplinary team as normative referents who would approve or disapprove of their adoption of the SDM behaviors. The most often reported barriers and facilitators for the behaviors concerned patients' characteristics, patients' clinical situation, and time.
Conclusions
The implementation of SDM in nutrition clinical practice can be guided by addressing dietitians' salient beliefs. Identifying these beliefs also provides the theoretical framework needed for developing a quantitative survey questionnaire to further study the determinants of dietitians' adoption of SDM behaviors.
doi:10.1186/1748-5908-6-57
PMCID: PMC3120721  PMID: 21631933
25.  Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review 
BMC Medicine  2011;9:46.
Background
Electronic health record (EHR) implementation is currently underway in Canada, as in many other countries. These ambitious projects involve many stakeholders with unique perceptions of the implementation process. EHR users have an important role to play as they must integrate the EHR system into their work environments and use it in their everyday activities. Users hold valuable, first-hand knowledge of what can limit or contribute to the success of EHR implementation projects. A comprehensive synthesis of EHR users' perceptions is key to successful future implementation. This systematic literature review was aimed to synthesize current knowledge of the barriers and facilitators influencing shared EHR implementation among its various users.
Methods
Covering a period from 1999 to 2009, a literature search was conducted on nine electronic databases. Studies were included if they reported on users' perceived barriers and facilitators to shared EHR implementation, in healthcare settings comparable to Canada. Studies in all languages with an empirical study design were included. Quality and relevance of the studies were assessed. Four EHR user groups were targeted: physicians, other health care professionals, managers, and patients/public. Content analysis was performed independently by two authors using a validated extraction grid with pre-established categorization of barriers and facilitators for each group of EHR users.
Results
Of a total of 5,695 potentially relevant publications identified, 117 full text publications were obtained after screening titles and abstracts. After review of the full articles, 60 publications, corresponding to 52 studies, met the inclusion criteria. The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities.
Conclusions
This systematic review presents innovative research on the barriers and facilitators to EHR implementation. While important similarities between user groups are highlighted, differences between them demonstrate that each user group also has a unique perspective of the implementation process that should be taken into account.
doi:10.1186/1741-7015-9-46
PMCID: PMC3103434  PMID: 21524315

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