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PubMedDate not supplied

A systems approach to purchasing and implementing new technology.

There are many risks associated with purchasing and implementing new technology. The challenge is to reduce these risks to gain maximum benefit from the new technology purchased. In the high-cost world of healthcare, there is little room for wasting time and money related to technology implementation. If the workflow of the current system is not adequately understood before purchasing and implementing a new technology, that technology may mask underlying problems and/or create new ones. The purpose of this article is to present a framework for analyzing the current process or system, identifying the strengths and the areas in need of improvement. A thorough understanding of the problems with the current system and the barriers to change is necessary to ensure the selection of the "right" technology and promote its implementation.

Choice Behavior↗
PubMed2004

Integrated telehealth: putting it all together and addressing the challenges.

The Integrated Telehealth Project of Malaysia is considered a principal enabler for the nation's Vision 2020 as well as the National Health Vision. Being in such an unenviable position, of being not only the pioneer for such an integrated project, but also with no benchmark to compare with, the project implementers have faced manifold challenges along the way. This chapter deals with some of the challenges and lessons learnt that have accumulated as the project progressed.

Computer Communication Networks↗
PubMedDate not supplied

Challenges of change: a qualitative study of chronic care model implementation.

PURPOSE: The Chronic Care Model (CCM) provides a conceptual framework for transforming health care for patients with chronic conditions; however, little is known about how to best design and implement its specifics. One large health care organization that tried to implement the CCM in primary care provided an opportunity to study these issues. METHODS: We conducted a qualitative, comparative case study of 5 of 18 group clinics 18 to 23 months after the implementation began. Built on knowledge of the clinics from a previous study of advanced access implementation, data included in-depth interviews with organizational leaders and varied clinic personnel, observation of clinic care processes, and review of written materials. RESULTS: Relatively small and highly variable care process changes were made during the study period. The change process underwent several marked shifts in strategy when initial efforts failed to achieve much and bore little resemblance to the change process used in the previously successful large-scale implementation of advanced access scheduling. Many barriers were identified, including too many competing priorities, a lack of specificity and agreement about the care process changes desired, and little engagement of physicians. CONCLUSION: These findings highlight specific organizational challenges with health care transformation in the absence of a blueprint more specific than the CCM. Effective models of organizational change and detailed examples of proven, feasible care changes still need to be demonstrated if we are to transform care as called for by the Institute of Medicine.

Ambulatory Care Facilities↗
PubMed2004

Hepatitis B: epidemiology and natural history.

Chronic infection with hepatitis B and its sequelae remains a major global health concern. Despite recommendations and implementation of vaccination programs, the health and economic burdens are still significant. People in endemic areas and immigrants from these areas need to be adequately screened and treated. HBeAg-negative chronic hepatitis is increasingly recognized with additional challenges in management. Programs implementing primary prophylaxis strategies such as vaccination of high-risk adult and adolescent groups should continue.

Disease Progression↗
PubMed2006

Designing theoretically-informed implementation interventions.

Clinical and health services research is continually producing new findings that may contribute to effective and efficient patient care. However, the transfer of research findings into practice is unpredictable and can be a slow and haphazard process. Ideally, the choice of implementation strategies would be based upon evidence from randomised controlled trials or systematic reviews of a given implementation strategy. Unfortunately, reviews of implementation strategies consistently report effectiveness some, but not all of the time; possible causes of this variation are seldom reported or measured by the investigators in the original studies. Thus, any attempts to extrapolate from study settings to the real world are hampered by a lack of understanding of the effects of key elements of individuals, interventions, and the settings in which they were trialled. The explicit use of theory offers a way of addressing these issues and has a number of advantages, such as providing: a generalisable framework within which to represent the dimensions that implementation studies address, a process by which to inform the development and delivery of interventions, a guide when evaluating, and a way to allow for an exploration of potential causal mechanisms. However, the use of theory in designing implementation interventions is methodologically challenging for a number of reasons, including choosing between theories and faithfully translating theoretical constructs into interventions. The explicit use of theory offers potential advantages in terms of facilitating a better understanding of the generalisability and replicability of implementation interventions. However, this is a relatively unexplored methodological area.

Journal Article↗
PubMed2005

Development of radiology prediction models using feature analysis.

RATIONALE AND OBJECTIVES: This article provides an introduction to prediction models and their application in diagnostic imaging research. Prediction models capitalize on the different degrees of association among variables to make a prediction of a health state, formulate a rule, or quantify individual contributions of various predictor variables. The purpose of this article is to elucidate the rationale, implication, and interpretation of prediction models using imaging features. MATERIALS AND METHODS: The techniques and challenges of developing, testing, and implementing prediction models are described. Prediction model development methods are similar to data-mining techniques. RESULTS: Learning objectives are to review prediction rule (model) methods, learn how prediction models may be applied to feature analysis, and understand the challenges of developing, testing, and implementing prediction models.

Decision Support Techniques↗
PubMed1997

"Just-in-time" clinical information.

The just-in-time (JIT) model originated in the manufacturing industry as a way to manage parts inventories process so that specific components could be made available at the appropriate times (that is, "just in time"). This JIT model can be applied to the management of clinical information inventories, so that clinicians can have more immediate access to the most current and relevant information at the time they most need it--when making clinical care decisions. The authors discuss traditional modes of managing clinical information, and then describe how a new, JIT model may be developed and implemented. They describe three modes of clinician-information interactions that a JIT model might employ, the scope of information that may be made available in a JIT model (global information or local, case-specific information), and the challenges posed by the implementation of such an information-access model. Finally, they discuss how JIT information access may change how physicians practice medicine, various ways JIT information may be delivered, and concerns about the trustworthiness of electronically published and accessed information resources.

Clinical Competence↗
PubMed1999

The World Health Organization International Consortium in Psychiatric Epidemiology (ICPE): initial work and future directions -- the NAPE Lecture 1998. Nordic Association for Psychiatric Epidemiology.

OBJECTIVE: To provide an overview of the World Health Organization (WHO) International Consortium in Psychiatric Epidemiology (ICPE), to introduce the World Mental Health 2000 (WMH2000) Initiative and to discuss methodological issues that the ICPE is grappling with in planning the WMH2000 Initiative. METHOD: We review the history, mission and organization of the ICPE and the rationale behind the WMH2000 Initiative. We review methodological research underlying major design and implementation decisions regarding the WMH2000 surveys. RESULTS: The ICPE is an international consortium created to facilitate cross-national comparative epidemiological research using the WHO Composite International Diagnostic Interview (CIDI). The first-phase core ICPE surveys, which we are currently analysing, include over 33 000 interviews in seven countries, with an additional set of over 30 000 interviews in seven countries ready to be added to the master file within the next year. The WMH2000 Initiative will include a third series of CIDI surveys that include an anticipated 100000 additional interviews in 10 countries. A series of complex methodological challenges confront us in designing and implementing the WMH2000 surveys. These include issues in the conceptualization and measurement of impairment and disablement, the implementation of standardized quality control procedures across countries, and the blending of epidemiological and clinical interviewing methods to obtain a valid cross-national characterization of disorder prevalences. Our current plans regarding these issues are discussed. CONCLUSION: Valid and representative general population epidemiological data on patterns, predictors and adverse consequences of psychiatric disorders are needed as a foundation for public health initiatives. The efforts of the ICPE promise to provide data of this sort for many regions in the world. Formidable methodological and logistical challenges arise in implementing this agenda, but we are confident that these challenges can be met by building on the firm foundation already established in the ongoing ICPE collaboration.

Data Collection↗
PubMed2000

Recruitment of American Indians and Alaska Natives into clinical trials.

Challenges in recruiting American Indians and Alaska Natives into cancer clinical trials are addressed in this article. Researchers, health care providers, and American Indian and Alaska Native patients face significant communication barriers when prevention or treatment trials are designed or implemented. For researchers, the challenges lie in understanding the cultural distinctiveness of individual tribes, coping with the family orientation of Indian subjects, dealing with the lack of standardized research measures, and defining the subject's pathway in seeking and obtaining healing and health care services. For providers, the challenges center on patient-provider communication, illness beliefs, transportation, and sociocultural barriers. This article explores these complex issues and offers recommendations for researchers and health care providers on conducting research in American Indian and Alaska Native populations.

Alaska↗
PubMed2003

Progress towards meningitis prevention in the conjugate vaccines era.

Acute bacterial meningitis is an important cause of morbidity and mortality among children less than five years old, Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis being the most important agents of bacterial meningitis in developing countries. The development of the conjugate vaccines in the beginning of the 90's, especially type b H. influenzae (Hib), and more recently the heptavalent pneumococcal and the serogroup C meningococcal vaccines, have contributed directly to changes in the epidemiological profile of these invasive diseases (direct effect) and of their carriage status (indirect effect). We review the impact of the Hib conjugate vaccine in Latin American countries, where this vaccine has been implemented, and the potential of pneumococcal and meningococcal conjugate vaccines for the reduction of meningitis worldwide. We also address constraints for the development and delivery of these vaccines and review new candidate state-of-the-art vaccines. The greatest challenge, undoubtedly, is to implement these vaccines worldwide, especially in the developing regions.

Bacterial Capsules↗
PubMed1995

A promotion ladder for teachers at Harvard Medical School: experience and challenges.

The authors describe the development, implementation, and institutionalization at Harvard Medical School of a promotion ladder that recognizes the teaching and scholarly contributions of full-time clinical faculty. They also discuss the challenges that arose during this process, for example, how to make the new track creditable and attractive to both the appointed faculty and the faculty at large. The criteria developed for promotion focus on a candidate's skills and accomplishments in teaching, scholarship, clinical work, and departmental service. The authors present the elements of these criteria for the three professional levels of the ladder and outline the appointment process, including the steps for consideration of a given promotion. The development of this teacher-clinician ladder has had a positive influence on faculty who are committed to teaching by allowing recognition of their contributions in a track held to be the equal of the other full-time tracks in a medical faculty traditionally committed to research and patient care. Data are given for the 70 faculty who were promoted over the five years from 1989 to 1994. The true success of this promotion ladder will be measured only over time through its impact on the educational enterprise within the medical school and its hospitals, and its capacity to both successfully advance the careers of qualified medical educators and further the development of the field of medical education.

Career Mobility↗
PubMed2005

Onchocerciasis control and elimination: coming of age in resource-constrained health systems.

During the past three decades, onchocerciasis control has been successful in reducing blindness and skin disease in Africa and the Americas. In this article, I review the control and elimination of Onchocerca volvulus as a public health problem. The success of onchocerciasis control has been the result of secure financing, generous drug donation, effective partnership between stakeholders, and focused operational and implementation research. The future challenges are to ensure sustainability of existing programmes and to increase the level of integration with other health interventions in resource-deficient health systems.

Animals↗
PubMed1997

Empirically validated family interventions for pediatric psychology: sickle cell disease as an exemplar.

Prompted by the growth of managed care and the American Psychological Association's recent guidelines for treatment efficacy studies, we have struggled with the challenges associated with devising and implementing manualized family intervention programs for pediatric patients. This manuscript outlines the strengths and challenges of controlled manual-based family interventions for medically ill children, using pediatric sickle cell disease (SCD) as an example. A culturally and developmentally sensitive intervention program, designed for the researcher's subject population (African American, low SES, inner city) is discussed. Possible solutions to the challenges of conducting family-oriented intervention efficacy studies with pediatric populations are presented.

Adolescent↗
PubMed1998

Completing advance directives for health care decisions: getting to yes.

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician-hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved--providers, patients, families, and payors--in this most profound process.

Advance Care Planning↗
PubMed2001

Challenging behaviour in community services.

The implementation of community care in the UK has led to the requirement that services should be able to meet the needs of adults with intellectual disability (ID) and additional needs in terms of challenging behaviour. However, the extent to which people with challenging behaviour are present in the community and the extent to which community services can support them effectively still requires significant research. The present study examines the prevalence of challenging behaviour amongst adults with ID residing in three London boroughs and the issues which arise from service delivery to this client group. All service providers and general practitioners in the area were contacted and asked to identify any individuals with ID and challenging behaviour. All responses were screened, and then key staff were interviewed for information on a range of demographic factors and on the Checklist of Challenging Behaviour. The reliability of the instrument was also assessed. Four hundred and forty-eight individuals were identified from a total borough population of 670 000. There was consistency in the types of behaviour which were frequently identified across the three boroughs. There were significant levels of self-injury as well as a range of behaviours of the 'hard to engage' type. Most individuals had more then one challenging behaviour and some individuals with seriously aggressive behaviour used local community services. Twenty-five per cent of the sample lived at home with their families and 50% were in community residential services. The boroughs differed in their ability to manage those with challenging behaviour in that one borough had many more people placed out-of-borough. Significant numbers of individuals with challenging behaviour were living in the community. The range and number of behaviours suggest that staff need to be very skilled in supporting such individuals, and that effective planning and support are essential if people with challenging behaviour are to be maintained in community settings.

Activities of Daily Living↗
PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗