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PubMed2001

A web implementation: the good and the not-so-good.

E-commerce, e-mail, e-greeting, e-this, and e-that everywhere you turn there is a new "e" word for an internet or Web application. We, at the Cleveland Clinic Foundation, have been "e-nlightened" and will discuss in this report the implementation of a web-based radiology information system (RIS) in our radiology division or "e-radiology" division. The application, IDXRad Version 10.0 from IDX Corp, Burlington, VT, is in use at the Cleveland Clinic Foundation and has both intranet (for use in Radiology) and internet (referring physician viewing) modules. We will concentrate on the features of using a web browser for the application's front-end, including easy prototyping for screen review, easier mock-ups of demonstrations by vendors and developers, and easier training as more people become web-addicted. Project communication can be facilitated with an internal project web page, and use of the web browser can accommodate quicker turnaround of software upgrades as the software code is centrally located. Compared with other technologies, including client/server, there is a smaller roll out cost when using a standard web browser. However, the new technology requires a change and changes are never implemented without challenges. A seasoned technologist using a legacy system can enter data quicker using function keys than using a graphical user interface and pointing and clicking through a series of pop-up windows. Also, effective use of a web browser depends on intuitive design for it to be easily implemented and accepted by the user. Some software packages will not work on both of the popular web browsers and then are tailored to specific release levels. As computer-based patient records become a standard, patient confidentiality must be enforced. The technical design and application security features that support the web-based software package will be discussed. Also web technologies have their own implementation issues.

Computer Communication Networks↗

PubMed2000

The ISO 14001 EMS Implementation Process and Its Implications: A Case Study of Central Japan.

/ This study aims to investigate the ISO 14001 implementation process and its implications for regional environmental management. The region of Central Japan (known as Chubu in Japanese, which literally means center) was chosen for this case study. The study focuses on selected issues such as the: (1) trends and motives of private firms in the implementation of an ISO 14001-based environmental management system (EMS); (2) obstacles during system implementation; (3) role of the system in enhancing environmental performance within the certified organization; and (4) relation between the major stakeholders, local citizens, governments, and firms after adopting the system. To achieve these objectives, a questionnaire survey was mailed to all certified firms in the region. A 58% response was achieved overall. The results show that the main aims behind the adoption of ISO 14001 by firms in the Chubu region are to improve the environmental aspects within the enterprises and to enhance the employees' environmental awareness and capacity. The results have also shown that the ISO 14001-based EMS has had a great effect on a firm's environmental status as certified firms have claimed that natural resources such as fuel, water, and paper consumption have been more efficiently managed after adopting the system. Implementation of the system causes the firms to consider the role of the local people and the government in more effectively involving the local people in the firm's daily environmental activities. It also helps to enhance the environmental awareness among the local people. Adopting the system also promotes a better relation within the enterprises affiliated to the same group, such as more attention given by the parent firms (head offices) towards other firms working for the same group, or branches-mainly small and medium sized enterprises (SMEs)-in the field of EMS. Finally, the results show that firms give serious consideration to their final products' impacts on the environment. In other words, attention is given to life cycle analysis (LCA) among certified firms.

Journal Article↗

PubMed2003

Barriers and strategies in implementation of oral care standards for cancer patients.

Oral complications of cancer therapy include mucositis, oral pain, poor oral intake, infection, bleeding, and difficulty communicating. Use of oral care standards can help manage these problems, but their systematic implementation is relatively rare. The purpose of this paper is to discuss barriers to implementing oral care standards, and to make suggestions for how such standards might be implemented in clinical settings. These purposes are accomplished through a review of relevant literature from various health-care disciplines, and discussion of one institution's implementation of an oral care standard for leukemia and bone marrow/stem cell transplant patients. Key principles underlying this successful institutional effort were recognition of the medical necessity of oral care, collaboration among health-care disciplines, and use of evidence-based practice wherever possible.

Bone Marrow Transplantation↗

PubMed2001

Implementing evidence based antiemetic guidelines in the oncology setting: results of a 4-month prospective intervention study.

There is a considerable gap between obtaining results in randomized trials and implementing them into practice. This is particularly relevant with the high-cost 5HT3 antiemetics, which include ondansetron, dolasetron and granisetron. Randomized trial data suggests that they should be used as a single daily dose during only the first 24 h of chemotherapy because they offer little benefit over less costly agents beyond this period. In this study, six intervention methods (i.e. multifaceted approach) were combined to change physicians' 5HT3 prescribing patterns to comply with evidence-based antiemetic guidelines. A six-step implementation process was adopted, consisting of guideline dissemination, the use of opinion leaders, interactive educational workshops, therapeutic reminders in the form of preprinted orders, clinical interventions by pharmacists for the event of inappropriate antiemetic orders, and physician audit and feedback. Once implemented, the control of emesis was collected in all patients who were enrolled in the intervention program. Multivariable regression analysis was then used to assess whether prescribing within antiemetic guidelines compromised patient care. A total of 195 inpatients were enrolled in the study over the 4-month intervention period. Overall, 88.7% of granisetron prescriptions fulfilled the guidelines with respect to appropriate indication, dosage, and duration of therapy. The multivariable analysis suggested that granisetron prescribing within guidelines did not compromise the control of acute and delayed emesis. In addition, patients who received evidence-based antiemetic therapy experienced a significant reduction in the severity of acute nausea [risk ratio (RR) = 0.69; P=0.03]. The results of this guideline implementation study revealed that a pharmacist-driven multifaceted intervention program for such high-cost agents as 5HT3 antiemetics can promote their use in a clinically appropriate manner and can save unnecessary drug costs without compromising the quality of patient care.

Adult↗

PubMed2006

Financial assessment of a picture archiving and communication system implemented all at once.

The objective of this study was to determine the differential cost between film-based radiology and a hospital-wide picture archiving and communication system (PACS) implemented all at once. The cash flow and running costs of PACS and film-based operation were measured over an 8-year time horizon. When the hospital-wide PACS was implemented over a short period, there was instant conversion into digital film and archives. The net present value (NPV) for PACS operation is US $1,598,698, whereas the NPV for film-based operation is US $2,083,856, indicating a net saving of US $485,157. The payback period is 4 years. The costs of computed radiography and image plates account for 40% of the initial capital expenditure in PACS implementation, followed by computer hardware (30%) and software (9%) costs. Our experience shows that implementation of hospital-wide PACS all at once can produce cost savings. For hospitals intending to go filmless, this study offers a model for financial evaluation of PACS to help in decision making.

Analog-Digital Conversion↗

PubMed2006

Clinicians' attitudes regarding barriers to the implementation of psychiatric advance directives.

OBJECTIVE: Psychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals. METHODS: A total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs. RESULTS: Across the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers' desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers. CONCLUSION: Psychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals' work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.

Adult↗

PubMed2006

Assessment of air quality after the implementation of compressed natural gas (CNG) as fuel in public transport in Delhi, India.

Public transport in Delhi was amended by the Supreme Court of India to use Compressed Natural Gas (CNG) instead of diesel or petrol. After the implementation of CNG since April 2001, Delhi has the highest fraction of CNG-run public vehicles in the world and most of them were introduced within 20 months. In the present study, the concentrations of various criteria air pollutants (SPM, PM(10), CO, SO(2) and NO(x)) and organic pollutants such as benzene, toluene, xylene (BTX) and polycyclic aromatic hydrocarbons (PAHs) were assessed before and after the implementation of CNG. A decreasing trend was found for PAHs, SO(2) and CO concentrations, while the NO(x) level was increased in comparison to those before the implementation of CNG. Further, SPM, PM(10), and BTX concentrations showed no significant change after the implementation of CNG. However, the BTX concentration demonstrated a clear relation with the benzene content of gasoline. In addition to the impact of the introduction of CNG the daily variation in PAHs levels was also studied and the PAHs concentrations were observed to be relatively high between 10 pm to 6 am, which gives a proof of a relation with the limited day entry and movement of heavy vehicles in Delhi.

Air↗

PubMed2006

Lessons learned in implementing evidence-based practices: implications for psychiatric administrators.

Factors related to the dissemination and implementation of evidence-based practices (EBPs) are discussed. Extensive effort is required to successfully implement and sustain EBPs that improve clinical outcomes. There is a rapid rate of discovery of new EBPs. Examples of large-scale implementations of EBPs in mental health are described with emphasis on the factors thought critical for success. The need for designing systems which can cost-effectively implement new EBPs is highlighted. Finally, the implications for psychiatric administrators are discussed.

Evidence-Based Medicine↗

PubMed2006

Evidence-based treatments in the field: a brief report on provider knowledge, implementation, and practice.

This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments.

Adult↗

PubMedDate not supplied

Implementation of the mastery learning/modular curriculum in nurse-midwifery education.

A survey of all nurse-midwifery programs in operation during 1987 was designed to answer the questions: (1) to what extent were elements of mastery learning being implemented in nurse-midwifery programs, and (2) were there patterns of implementation associated with particular organizational characteristics of the programs. Mastery learning was introduced in nurse-midwifery education in 1972; in this study elements of mastery learning were found to be widely implemented in both mastery and non-mastery learning programs. Data about organizational characteristics of the programs revealed them to be homogeneous in several respects. There were no important differences in implementation of elements of mastery learning associated with the organizational characteristics studied.

Curriculum↗

PubMed1987

The implementation of postgraduate training programs through state and local resources.

A profile of implementation strategies for funding postgraduate training programs using local or state resources is described. The need for those implementation strategies as well as basic principles for successful implementation is documented. Two programs are briefly described--a University Affiliated Program (UAP) in western New York and a UAP in Missouri--as the basis for generating implementation strategies. Finally a discussion is provided reviewing the strengths and weaknesses of these strategies.

Developmental Disabilities↗

PubMed1996

A Numerical Implementation of Kolmogorov's Superpositions.

Hecht-Nielsen proposed a feedforward neural network based on Kolmogorov's superpositionsf(x(i), em leader,x(n))= summation operator q=02piPhi(q)(y(q)) that apply to all real valued continuous functions f(x(1), em leader, x(n)) defined on a Euclidean unit cube of dimension n >/= 2. This network has a hidden layer that is independent of f and that transforms the n-tuples (x(1), em leader, x(n)) into the 2n + 1 variables y(q), and an output layer in which f is computed. Kůrková has shown that such a network has an approximate implementation with arbitrary activation functions of sigmoidal type. Actual implementation is, however, impeded by the lack of numerical algorithms for the hidden layer which contain continuous functions of the formy(q)=Sigma(n)(p=1)alpha(p)psi(x(p)+qa) with constants a and alpha(p). This paper gives an explicit numerical implementation of the hidden layer that also enables the implementation of the output layer. Copyright 1996 Elsevier Science Ltd

Journal Article↗

PubMed2007

Guideline implementation fails to improve thrombolytic administration.

BACKGROUND: International randomised controlled trials conducted over the last two decades have consistently demonstrated improved mortality and morbidity resulting from thrombolytic therapy for patients with acute myocardial infarction (AMI). Subsequently, evidence-based guidelines have been designed and implemented to optimize thrombolytic delivery. The effect of evidence-based clinical guidelines on clinical practice is heavily influenced by strategies used to develop, disseminate and implement those guidelines. AIMS: This study evaluated the impact of a collaborative, multifaceted implementation strategy for AMI management guidelines on thrombolytic usage in the Loddon Mallee Region, Victoria, Australia. INTERVENTION: The multi-faceted implementation strategy included an inter-disciplinary team representing all treating venues contributing to the content of the "Guidelines for the Early Management of Acute Myocardial Infarction" followed by education sessions that coincided with the dissemination of the guidelines. METHODS: A retrospective medical records audit 12 weeks before and 12 weeks after the intervention was used to evaluate the impact on proportion of those patients eligible and receiving a thrombolytic and door-to-needle time. Variables of treating venue, age, gender, type of AMI, and type of transport to hospital were also measured to determine their impact on results. RESULTS AND CONCLUSIONS: A retrospective audit of 170 medical records found that the intervention appeared to have had no impact on the proportion of patients eligible and receiving a thrombolytic (74.2% vs. 62.5%: p=0.275), and door-to-needle time (67.7 min vs. 60.5 min: p=0.759). Venue specific influences produced a variety of patterns in thrombolytic delivery that require further exploration. This suggests that a single solution approach across multiple venues will have limited impact.

Adult↗

PubMed2026

A hybrid effectiveness-implementation trial to integrate precision skin cancer risk feedback in federally qualified health centers.

BACKGROUND: Skin cancers are the most common type of cancer in the United States, occur in all segments of the population, and are preventable. Our previous research with primary care patients' demonstrated interest in and efficacy of a precision prevention intervention providing feedback on MC1R risk level (higher versus average) in combination with prevention education materials relative to a standard educational intervention. Our current study is a hybrid type 1 effectiveness-implementation trial deployed at six federally-qualified health centers. This paper presents the study protocol. METHODS: A community advisory panel will guide development of study materials and measures. Staff training at each clinic will be completed in-person. Patients will be approached and screened in-person. Those completing genetic testing and the baseline survey will be randomized to the precision versus standard intervention for each risk level with a target sample size of 286 for each combination. Primary outcomes of effectiveness, assessed at 6 and 12 months, include a tanning score (5 items assessing intentional and unintentional tanning), number of sunburns, conduct of a skin self-examination, and electronic health record documentation of clinician-patient communication about skin cancer prevention. Effectiveness comparisons will focus on the precision relative to the standard intervention among higher risk participants. Implementation data will be collected to identify barriers and facilitators. RESULTS: Effectiveness and implementation outcomes will be evaluated following study completion. CONCLUSIONS: Results will guide subsequent scale-up of the precision intervention, including modifications of the intervention as well as methods for implementation. CLINICAL TRIALS IDENTIFIER: NCT07222995.

Humans↗

PubMed2004

Genomic biomarkers for cancer assessment: implementation challenges for laboratory practice.

Genomic biomarkers are an emerging class of laboratory tests, which present special implementation challenges for clinical laboratory services, compared to conventional laboratory tests. These challenges, which include analytical, bioinformatics, bioethical, interpretation and commercialization issues, represent real obstacles to widespread implementation of these tests. Technical challenges include the capacity to detect and identify many different kinds of markers for different diseases in a short time period, capacity to identify simultaneously gene rearrangements, amplification, inhibition, deletions and replications. Bioinformatics challenges include rapid analysis of genomic data, as well as the cross reference to other genomic data, and to other laboratory tests. Bioethical issues relate to consent to retain and use genetic data, which may be obtained inadvertently during analysis for genomic markers. Interpretation challenges include observations that the particular genomic markers may not be independent variables, as other undetected genomic alterations could invalidate or alter genomic marker interpretation. Further, as early experience with predictive genetic markers for cancer has shown, proprietary commercial interests may conflict with public health values of identifying genomic markers in subject populations. Based on our 10 years of experience with genomic biomarkers, important implementation strategies for genomic markers include development of:Standard high throughput analyzers capable of detecting any alteration of any genomic variant at any time. Bioinformatics analysis online, coupled to stored patient data. Laboratory service framework that preserves confidentiality but integrates genomic data with other laboratory tests. Laboratory service framework, which links consents, genomic analysis, reports to both specimen and data repositories. Overall, the laboratory service challenges for genomic markers are to manage very large analytical sets and very large data sets in finite time with responsible interpretation, all within finite funding. To meet these challenges, implementation strategies beyond the one disease, one diagnosis, one genomic marker concept must begin now.

Biomarkers, Tumor↗

PubMed2004

Design and implementation of a web-enabled haematological system.

This paper describes the design and the implementation of a web-enabled integrated haematological system, named e-HS. The proposed system runs on a set of distributed network nodes providing useful haematological services. These services include patient-oriented data management, digitized histopathological slides (DHS) acquisition, teleconsulting facilities, etc. The objective of e-HS is to supply web-enabled services according to haematological requirements, implement a distributed storage scheme for DHS, and provide a common database containing all haematological laboratory results by using eXtensible Markup Language (XML) and web technologies. Our implementation can be accessible to every authorized physician at the distributed nodes without any additional software. The only software required for the user is the widely used browser (e.g. MS Internet Explorer v 3.02 or higher). Besides, by using a self-explaining user interfaces and HTML-techniques, such as hyperlinks, the necessary amount of training at the physicians-side is reduced to a minimum. A first implementation of the e-HS, has been established at the Medical Physics Department of the University of Patras (master node of the system), and has been tested with success by the medical staff of the Hospital Departments of the University of Patras and Thessalonica that served as distributed nodes of the system.

Clinical Laboratory Information Systems↗

PubMed2005

Recruitment and implementation strategies in randomised controlled trials of acupuncture and herbal medicine in women's health.

INTRODUCTION: Recruitment of subjects to clinical trials is known to be difficult and there is little research describing recruitment and implementation strategies to CAM clinical trials. This paper describes the experiences from recruitment and implementation for five randomised controlled trials in women's health conducted in South Australia. METHODS: Descriptive study reporting on trial documentation and questionnaires completed by women. RESULTS: Recruitment rates varied between trials and a variety of recruitment strategies were used between studies. Promotion of the trials to the wider community were facilitated by issuing press releases and subsequent reporting by the media. Women found the trial acceptable suggesting factors motivating and preventing women from participating were well addressed. CONCLUSION: It is hoped that the experiences described here will give some insight to recruitment and implementation strategies. There is a need for more systematic research and evaluation of these strategies, and dissemination of these findings to assist with successful implementation of trials.

Acupuncture Therapy↗

PubMed2005

Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain.

BACKGROUND AND PURPOSE: The treatment for patients with low back pain varies considerably. The Dutch Physiotherapy Association issued an evidence-based physiotherapy guideline for non-specific low back pain. To establish changes in daily practice an active implementation strategy was developed. We evaluated the cost-effectiveness of this implementation strategy. SUBJECTS: 113 physiotherapists included 500 patients with low back pain. METHODS: In the intervention group the guideline was implemented actively, in the control group the standard method of dissemination was used. The patients filled in questionnaires at baseline and 6, 12, 26 and 52 weeks later. Direct medical costs, productivity costs (due to absenteeism) and quality of life (EQ-5D) were calculated. RESULTS: During the 1-year follow up, no differences were found in the quality of life, direct medical costs and productivity costs. CONCLUSION: The active implementation strategy appears not to be cost effective as compared to the standard strategy.

Adult↗