Barriers to implementation of a computerized decision support system for depression: an observational report on lessons learned in "real world" clinical settings

<p>Abstract</p> <p>Background</p> <p>Despite wide promotion, clinical practice guidelines have had limited effect in changing physician behavior. Effective implementation strategies to date have included: multifaceted interventions involving audit and feedback, local consensus processes, marketing; reminder systems, either manual or computerized; and interactive educational meetings. In addition, there is now growing evidence that contextual factors affecting implementation must be addressed such as organizational support (leadership procedures and resources) for the change and strategies to implement and maintain new systems.</p> <p>Methods</p> <p>To examine the feasibility and effectiveness of implementation of a computerized decision support system for depression (CDSS-D) in routine public mental health care in Texas, fifteen study clinicians (thirteen physicians and two advanced nurse practitioners) participated across five sites, accruing over 300 outpatient visits on 168 patients.</p> <p>Results</p> <p>Issues regarding computer literacy and hardware/software requirements were identified as initial barriers. Clinicians also reported concerns about negative impact on workflow and the potential need for duplication during the transition from paper to electronic systems of medical record keeping.</p> <p>Conclusion</p> <p>The following narrative report based on observations obtained during the initial testing and use of a CDSS-D in clinical settings further emphasizes the importance of taking into account organizational factors when planning implementation of evidence-based guidelines or decision support within a system.</p

STUDIES ON GANGRENE FOLLOWING COLD INJURY. IV. THE USE OF FLUORESCEIN AS AN INDICATOR OF LOCAL BLOOD FLOW: DISTRIBUTION OF FLUORESCEIN IN BODY FLUIDS AFTER INTRAVENOUS INJECTION

The use of fluorescein as a means of de-termining the adequacy of blood flow and the degree of capillary permeability in both normal individuals and in those manifesting various pathological states has been described in a series of papers by Kurt Lange and his associates (1, 2, 3). In general, the method depends upon the introduction of fluorescein into the blood stream and its detection by exposing the region under study to ultraviolet light. Data have been obtained by direct observations, photographic re-cording, and photoelectric registration of the yel-low-green glow which results from the excita-tion of fluorescein in the tissues. It is obvious that the appearance of fluorescence in tissues re-mote from the site of injection of fluorescein demonstrates the existence of circulating blood within the area under observation. However, the interpretation of the significance of grada-tions in the intensity of fluorescence, the rate at which maximum intensity is reached, and the rate at which it diminishes requires detailed knowl-edge of the properties of fluorescein and the man-ner in which it becomes distributed in blood and tissue fluid. Changes in the time-intensity relationships of fluorescence after the intravenous injection of fluorescein have been used recently as the basis for explanations of certain abnormalities present in myxedema and in tissues subjected to severe injury by cold (4, 5). In both of these widely different abnormal states, certain of the diver-gences from normal in the distribution of fluor-escein were attributed to changes in capillary permeability. While there is no doubt that th