Using the diffusion of innovations theory to assess socio-technical factors in planning the implementation of an electronic health record alert across multiple primary care clinics

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

The role of organizational culture in health information technology implementations: A scoping review

Introduction

Methods

Results

Conclusions

[Primary Healthcare e-SUS: determinant attributes for the adoption and use of a technological innovation]

The study aimed to analyze the adoption and use of the Primary Healthcare e-SUS (PHC e-SUS) as a technological innovation from the perspective of workers in primary healthcare (PHC). This was a sequential exploratory mixed-methods study (QUAN → qual) in municipalities in the interior of São Paulo state, Brazil, drawing on Diffusion of Innovation Theory. The quantitative component was analytical cross-sectional, applying a validated questionnaire to 114 PHC workers. The model was tested by applying partial least squares structural equation modeling (PLS-SEM) using SmartPLS 2.3.0. The qualitative study was descriptive-exploratory, using interviews (n = 10) with thematic content analysis, aimed at understanding the attributes that did not influence the adoption and use of PHC e-SUS. The attributes "experimentation", "ease of use", "relative advantage", and "compatibility" did not display statistical significance, indicating that they were not determinant attributes for the adoption and use of PHC e-SUS. Integration of the data evidenced failures in connectivity; lack of time to feed the system in real time and training; lack of prior experimentation; abrupt presentation of the system; and lack of skill with the technology. The results can assist other municipalities in Brazil with the implementation of the PHC e-SUS in relation to the importance of the organizational infrastructure, as well as training in the technology's use and handling. The study contributes to reflections and proposals for interventions in the problems faced in daily work with the adoption and use of a technological innovation such as the PHC e-SUS.

Theories Informing eHealth Implementation: Systematic Review and Typology Classification

Background

Theory-guided approaches to implementation science have informed translation efforts and the acceptance of eHealth (digital health) interventions in clinical care. However, there is scarce evidence on which theories are best suited to addressing the inherent complexity of eHealth implementation.

Objective

The objectives of this systematic review are to identify theories that inform and explain eHealth implementation and to classify these theories using the typology by Sovacool and Hess for theories of sociotechnical change.

Methods

An electronic search was conducted in the PsycINFO, MEDLINE, Embase, CINAHL, Scopus, Sociological Source Ultimate, Web of Science, ABI/INFORM, EBSCO, and ProQuest databases in June 2019. Studies were included if they were published between 2009 and June 2019; were written in English; reported on empirical research, regardless of study or publication type; reported on one or more theories in the context of eHealth implementation; and were published in a peer-reviewed journal. A total of 2 reviewers independently assessed the titles, abstracts, and full texts. Theories identified were classified using a typology for theories of sociotechnical change, which was considered a useful tool for ordering and analyzing the diverse theoretical approaches as a basis for future theory building.

Results

Of the 13,101 potentially relevant titles, 119 studies were included. The review identified 36 theories used to explain implementation approaches in eHealth. The most commonly used approaches were the Technology Acceptance Model (TAM) (n=33) and the Unified Theory of Acceptance and Use of Technology (UTAUT) (n=32). These theories were primarily concerned with individual and interpersonal elements of eHealth acceptance. Less common were theories that reflect the various disorderly social processes and structural dimensions of implementation, such as the normalization process theory (n=17) and the structuration theory (n=6).

Conclusions

Theories currently informing the implementation of eHealth interventions predominantly focus on predicting or explaining end-user acceptance. Theoretical perspectives that capture the dense and intricate relationships and structures required to enact sustainable change are less well represented in the eHealth literature. Given the growing acknowledgment of the inherent complexity of eHealth implementation, future research should develop and test models that recognize and reflect the multidimensional, dynamic, and relational nature of this process.

Prescribing Variation in General Practices in England Following a Direct Healthcare Professional Communication on Mirabegron

Introduction: Pharmacovigilance may detect safety issues after marketing of medications, and this can result in regulatory action such as direct healthcare professional communications (DHPC). DHPC can be effective in changing prescribing behaviour, however the extent to which prescribers vary in their response to DHPC is unknown. This study aims to explore changes in prescribing and prescribing variation among general practitioner (GP) practices following a DHPC on the safety of mirabegron, a medication to treat overactive bladder (OAB). Methods: This is an interrupted time series study of English GP practices from 2014–2017. National Health Service (NHS) Digital provided monthly statistics on aggregate practice-level prescribing and practice characteristics (practice staff and registered patient profiles, Quality and Outcomes Framework indicators, and deprivation of the practice area). The primary outcome was monthly mirabegron prescriptions as a percentage of all OAB drug prescriptions and we assessed the change following a DHPC issued by the European Medicines Agency in September 2015. The DHPC stated mirabegron use was contraindicated with severe uncontrolled hypertension and cautioned with hypertension. Variation between practices in mirabegron prescribing before and after the DHPC was assessed using the systematic component of variation (SCV). Multilevel segmented regression with random effects quantified the change in level and trend of prescribing after the DHPC. Practice characteristics were assessed for their association with a reduction in prescribing following the DHPC. Results: This study included 7408 practices. During September 2015, 88.9% of practices prescribed mirabegron and mirabegron comprised a mean of 8.2% (SD 6.8) of OAB prescriptions. Variation between practices was classified as very high and the median SCV did not change significantly (p = 0.11) in the six months after the September 2015 DHPC (12.4) compared to before (11.6). Before the DHPC, the share of mirabegron over all OAB drug prescriptions increased by 0.294 (95% confidence interval (CI), 0.287, 0.301) percentage points per month. There was no significant change in the month immediately after the DHPC (−0.023, 95% CI −0.105 to 0.058), however there was a significant reduction in trend (−0.036, 95% CI −0.049 to −0.023). Higher numbers of registered patients, patients aged ≥65 years, and practice area deprivation were associated with having a significant decrease in level and slope of mirabegron prescribing post-DHPC. Conclusion: Variation in mirabegron prescribing was high over the study period and did not change substantively following the DHPC. There was no immediate prescribing change post-DHPC, although the monthly growth did slow. Knowledge of the degree of variation in and determinants of response to safety communications may allow those that do not change prescribing habits to be provided with additional support.