The diffusion of an evidence-based disease guidance system for managing stroke

Impact of Guidelines on the Diffusion of Medical Technology: A Case Study of Cardiac Resynchronization Therapy in the UK

INTRODUCTION

Research on clinical practice guidelines as a determinant of the diffusion of medical technology remains sparse. We aim to evaluate the impact of guidelines on the awareness of medical technology, as a proxy of its use, with the example of cardiac resynchronization therapy (CRT) in the United Kingdom (UK).

METHODS

We measured clinician awareness based on Google searches performed for CRT that corresponded with actual CRT implant numbers provided by the European Heart Rhythm Association (EHRA). We identified the guideline recommendations published by the National Institute of Health and Care Excellence (NICE) within the UK, the European Society of Cardiology (ESC) at the European level, and the American College of Cardiology Foundation/American Heart Association in the United States (US). We specified a dynamic moving average model, with Google searches as the dependent variable and guideline changes as the independent variables.

RESULTS

One guideline change published by NICE in 2007 and two changes released by the US guidelines in 2005 and 2012 were significantly correlated with the Google searches (p = 0.08, p = 0.02, and p = 0.02, respectively). Guideline changes by the ESC had no significant impact. Changes recommending CRT in place of a conventional pacemaker, in patients with atrial fibrillation, and restricting CRT due to contraindication, remained universally uninfluential.

CONCLUSION

The factors associated with a lack of awareness (as a proxy for technology diffusion) in our case study were: a lack of strong clinical evidence that resulted in the moderate strength of a recommendation, a lack of recognition of any externally published recommendation by NICE, and the frequent release of guidelines with minor changes targeting small patient groups. At least in our case, in the absence of NICE guidelines, the US guidelines received more attention than their non-UK European counterparts, even if the former were released after the latter.

Diffusing an Innovation: Clinician Perceptions of Continuous Predictive Analytics Monitoring in Intensive Care

BACKGROUND

The purpose of this article is to describe neonatal intensive care unit clinician perceptions of a continuous predictive analytics technology and how those perceptions influenced clinician adoption. Adopting and integrating new technology into care is notoriously slow and difficult; realizing expected gains remain a challenge.

METHODS

Semistructured interviews from a cross-section of neonatal physicians (n = 14) and nurses (n = 8) from a single U.S. medical center were collected 18 months following the conclusion of the predictive monitoring technology randomized control trial. Following qualitative descriptive analysis, innovation attributes from Diffusion of Innovation Theory-guided thematic development.

RESULTS

Results suggest that the combination of physical location as well as lack of integration into work flow or methods of using data in care decisionmaking may have delayed clinicians from routinely paying attention to the data. Once data were routinely collected, documented, and reported during patient rounds and patient handoffs, clinicians came to view data as another vital sign. Through clinicians' observation of senior physicians and nurses, and ongoing dialogue about data trends and patient status, clinicians learned how to integrate these data in care decision making (e.g., differential diagnosis) and came to value the technology as beneficial to care delivery.

DISCUSSION

The use of newly created predictive technologies that provide early warning of illness may require implementation strategies that acknowledge the risk-benefit of treatment clinicians must balance and take advantage of existing clinician training methods.

Integrative review of benefit levers' characteristics for system-wide spread of best healthcare practices

AIM

To critically analyse the characteristics of the benefit levers that are required for effective system-wide spread of evidence-based practice.

BACKGROUND

Evidence-based nursing practice is the cornerstone of quality patient care and merits system-wide implementation. Achieving system-wide spread of evidence-based innovations requires adoption of four benefit levers (the facilitators for spreading innovations), conceptualized by Edwards and Grinspun: alignment, leadership for change, permeation plans and supporting and reinforcing structures. Although these concepts have been explored and described in primary studies, they were only recently identified as benefit levers and their characteristics have not been reviewed in the context of health care using an integrative literature review.

DESIGN

An integrative literature review using an adapted Whittemore and Knafl design.

DATA SOURCES

A comprehensive search using multiple sites such as Scopus, EBSCOhost, ProQuest, ScienceDirect, Cochrane Library, Nexus, SAePublications, Sabinet, Google Scholar and grey literature was conducted (January-March 2012) and updated (December 2014). After reading the abstracts, titles and full-text articles, forty (N = 40) research and non-research documents met the inclusion criteria.

REVIEW METHODS

Thirty-five documents remained after critical appraisal. A systematic approach was used to analyse and synthesize the data and formulate concluding statements.

RESULTS

Data revealed characteristics about alignment (personal, organizational and contextual attributes), permeation plans (phases), leadership for change (types, strategies, position, attitude and support) and supporting and reinforcing structures (types and requirements).

CONCLUSION

Benefit levers should be used to promote the spread of evidence-based practices. However, more studies concerning benefit levers, specifically regarding 'alignment' and 'permeation plans', are required to promote system-wide spread of best healthcare practices.

Making sense of health information technology implementation: A qualitative study protocol

Background

Implementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions.

Methods

In this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns.

Discussion

Outcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals.

For what purpose and reasons do doctors use the Internet: a systematic review

OBJECTIVES

To determine doctors' reasons for using the Internet, and the factors that influence their usage.

DATA SOURCES

A systematic review of 38 studies, from 1994 to 2004, describing surveys of doctors' Internet usage.

RESULTS

All of the studies were in the developed world, primarily in North America. Approximately 60-70% of doctors have access to the Internet, but in several studies access is more than 90%. Access is steadily increasing. Most Internet activity focuses on email and searching in journals and databases, but there is a very wide range of activities. Professional email with colleagues and patients is low, but increasing. The major factors discouraging usage are time, workload and cost, while too much information, liability issues and lack of skills also feature as discouraging factors. Factors encouraging use are unclear, but overall patient satisfaction and belief in improved service delivery, time saving and demand from patients are factors. There is a trend that males use the Internet more than females, young more than old, and specialists more than generalists, but these differences are not across the board, and show variations between studies.

CONCLUSION

In spite of the limitations, it is clear that doctors are highly connected to the Internet, and their professional usage is increasing. Factors encouraging and discouraging usage are more complex than simple connectivity. Usage differences between demographic groups do exist, but are equalising. More and consistent research is required in this area.

Clarifying the concepts in knowledge transfer: a literature review

AIM

The aim of this paper is to examine the concepts of opinion leaders, facilitators, champions, linking agents and change agents as described in health, education and management literature in order to determine the conceptual underpinnings of each.

BACKGROUND

The knowledge utilization and diffusion of innovation literature encompasses many different disciplines, from management to education to nursing. Due to the involvement of multiple specialties, concepts are often borrowed or used interchangeably and may lack standard definition. This contributes to confusion and ambiguity in the exactness of concepts.

METHODS

A critical analysis of the literature was undertaken of the concepts opinion leaders, facilitators, champions, linking agents and change agents. A literature search using the concepts as keywords was conducted using Medline, CINAHL, Proquest and ERIC from 1990 to March 2003. All papers that gave sufficient detail describing the various concepts were included in the review. Several 'older' papers were included as they were identified as seminal work or were frequently cited by other authors. In addition, reference lists were reviewed to identify books seen by authors as essential to the field.

FINDINGS

Two similarities cut across each of the five roles: the underlying assumption that increasing the availability of knowledge will lead to behaviour change, and that in essence each role is a form of change agent. There are, however, many differences that suggest that these concepts are conceptually unique.

CONCLUSIONS

There is inconsistency in the use of the various terms, and this has implications for comparisons of intervention studies within the knowledge diffusion literature. From these comparisons, we concluded that considerable confusion and overlap continues to exist and these concepts may indeed be similar phenomena with different labels. All concepts appear to be based on the premise that interpersonal contact improves the likelihood of behavioural change when introducing new innovations into the health sector.

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.