Methodological reflections on the evaluation of the implementation and adoption of national electronic health record systems

Copyright @ 2012, International Journal of Integrated Care (IJIC). This work is licensed under a (http://creativecommons.org/licenses/by/3.0) Creative Commons Attribution 3.0 Unported License.Introduction/purpose of presentation: Far-reaching policy commitments to information technology-centered transformations of healthcare systems have now been made in many countries. There is as yet little empirical evidence to justify such decisions, hence the need for rigorous independent evaluation of current implementation efforts. Such evaluations however pose a number of important challenges. This presentation has been designed as a part of a Panel based on our experience of evaluating the National Health Service’s (NHS) implementation of electronic health records (EHR) systems in hospitals throughout England. We discuss the methodological challenges encountered in planning and undertaking an evaluation of a program of this scale and reflect on why and how we adapted our evaluation approach—both conceptually and methodologically—in response to these challenges. Study design/population studied: Critical reflections on a multi-disciplinary and multi-facet independent evaluation of a national program to implement electronic health record systems into 12 ‘early wave’ NHS hospitals in England. Findings: Our initial plan was to employ a mixed methods longitudinal ‘before-during-after’ study design. We however found this unsustainable in the light of fluxes in policy, contractual issues and over-optimistic schedules for EHR deployments. More importantly, this research design failed adequately to address the core of multi-faceted evolving EHRs as understood by key stakeholders and as worked out in their distinct work settings. Thus conventional outcomes-centric evaluations may not easily scale-up when evaluating transformational programs and may indeed prove misleading. New assumptions concerning the implementation process of EHR need to be developed that recognize the constantly changing milieu of policy, product, projects and professions that are inherent to such national implementations. The approaches we subsequently developed substitute the positivist view that EHR initiatives are self-evident and self-contained interventions, which are amenable to traditional quantitative evaluations, to one that focuses on how they are understood by various stakeholders and made to work in specific contexts. These assumptions recast the role of evaluation towards an approach that explores and interprets processes of socio-technical change that surround EHR implementation and adoption as seen by multiple stakeholders. Conclusions and policy implications: There is likely to be an increase in politically-driven national programs of reform of healthcare based on information and communication technologies. Programs on such a scale are inherently complex with extended temporalities and extensive and dynamic sets of stakeholders. They are, in short, different and pose new evaluation challenges that previously formulated evaluation methods for health information systems cannot easily address. This calls for methodological innovation amongst research teams and their supporting bodies. We argue that evaluation of such system-wide transformation programs are likely to demand both breadth and depth of experience within a multidisciplinary research team, constant questioning of what is and what can be evaluated and how, and a particular way of working that emphasizes continuous dialogue and reflexivity. Making this transition is essential to enable evaluations that can usefully inform policy-making. Health policy experts urgently need to reassess the evaluation strategies they employ as they come to address national policies for system-wide transformation based on new electronic health infrastructures

Estimation of Export Supply Function for Citrus Fruit in Pakistan

There is strong evidence in the literature that export and economic growth have a positive relationship. In Pakistan, with an agrarian economy, earnings from primary agricultural exports are vital for the overall growth process. Fruits are the traditional export commodities, which contribute more than half of total export earnings from primary agricultural commodities. The persistent instability in world market prices for primary commodities has depressed the export earnings from these commodities over time. This poses great challenges to a country like Pakistan. The present study aims at examining changes in the volume of export of citrus fruit from Pakistan caused by such factors as changes in domestic and export prices, national product, foreign exchange rate, etc. The study uses time series data for the period 1975–2004 for citrus exports and related domestic price, export price, GDP, and foreign exchange rate, employing the co-integration and error correction techniques for analysis purposes.

Leptogenesis from Gravity Waves in Models of Inflation

We present a new mechanism for creating the observed cosmic matter-antimatter asymmetry which satisfies all three Sakharov conditions from one common thread, gravitational waves. We generate lepton number through the gravitational anomaly in the lepton number current. The source term comes from elliptically polarizated gravity waves that are produced during inflation if the inflaton field contains a CP-odd component. In simple inflationary scenarios, the generated matter asymmetry is very small. We describe some special conditions in which our mechanism can give a matter asymmetry of realistic size.Comment: 4 pages, RevTeX4.1 format; an error in computations correcte

Revisiting Cosmic No-Hair Theorem for Inflationary Settings

In this work we revisit Wald's cosmic no-hair theorem in the context of accelerating Bianchi cosmologies for a generic cosmic fluid with non-vanishing anisotropic stress tensor and when the fluid energy momentum tensor is of the form of a cosmological constant term plus a piece which does not respect strong or dominant energy conditions. Such a fluid is the one appearing in inflationary models. We show that for such a system anisotropy may grow, in contrast to the cosmic no-hair conjecture. In particular, for a generic inflationary model we show that there is an upper bound on the growth of anisotropy. For slow-roll inflationary models our analysis can be refined further and the upper bound is found to be of the order of slow-roll parameters. We examine our general discussions and our extension of Wald's theorem for three classes of slow-roll inflationary models, generic multi-scalar field driven models, anisotropic models involving U(1) gauge fields and the gauge-flation scenario.Comment: 21 pp, 4 .eps figure

Three-component Synthesis of Electron-poor Alkenes using Isatin Derivatives, Acetylenic Esters, Triphenylphosphine and Theoretical Study

Synthesis of electron-poor alkenes has been reported by 1,2-proton shift and elimination of triphenyl phosphine from phosphorus ylide in good to high yields. The structures of six novel products were deduced fromtheir IR, 1HNMR, and 13CNMRspectra. The B3LYP/HF calculations for computation of 1H and 13C NMR chemical shifts have been carried out for the compounds with the 6-31G* basis set utilizing the GIAOapproach. In addition, theoretical configurations of the title compound were studied in terms of the combined analysis of the HOMO–LUMO energy gap, NBO analysis, thermodynamic parameters and molecular electrostatic potential (MEP). Also ionization potential (I), electron affinity (A), chemical hardness (ç), electronic chemical potential (μ) and electrophilicity (ù) of the title molecule are reported. All calculations were  performed using B3LYP method with the 6-31G* basis set.KEYWORDS: Isatin, electron-poor alkenes, DFT, NBO, HOMO, LUMO

Re-appearance of the pairing correlations at finite temperature

Rotational and deformation dependence of isovector and isoscalar pairing correlations at finite temperature are studied in an exactly solvable cranked deformed shell model Hamiltonian. It is shown that isovector pairing correlations, as expected, decrease with increasing deformation and the isoscalar pairing correlations remain constant at temperature, T=0. However, it is observed that at finite temperature both isovector and isoscalar pairing correlations are enhanced with increasing deformation, which contradict the mean-field predictions. It is also demonstrated that the pair correlations, which are quenched at T=0 and high rotational frequency re-appear at finite temperature. The changes in the individual multipole pairing fields as a function of rotation and deformation are analyzed in detail.Comment: 16 pages 6 figure

Isovector and isoscalar superfluid phases in rotating nuclei

The subtle interplay between the two nuclear superfluids, isovector T=1 and isoscalar T=0 phases, are investigated in an exactly soluble model. It is shown that T=1 and T=0 pair-modes decouple in the exact calculations with the T=1 pair-energy being independent of the T=0 pair-strength and vice-versa. In the rotating-field, the isoscalar correlations remain constant in contrast to the well known quenching of isovector pairing. An increase of the isoscalar (J=1, T=0) pair-field results in a delay of the bandcrossing frequency. This behaviour is shown to be present only near the N=Z line and its experimental confirmation would imply a strong signature for isoscalar pairing collectivity. The solutions of the exact model are also discussed in the Hartree-Fock-Bogoliubov approximation.Comment: 5 pages, 4 figures, submitted to PR