Prehospital Electronic Patient Care Report Systems: Early Experiences from Emergency Medical Services Agency Leaders

Background: As the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies. Methods: We conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes. Results: Twenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity. Conclusion: EMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies

Nonhuman Resource Practices: Control, Conformity and Contestation

The aim of this chapter will be to consider how human resource procedures, policies, systems and documentation are deployed to control others and achieve conformity to organisational goals. As an insider ethnographic account it is also possible to demonstrate how the interpretation of these policies, practices, systems and documents are contested. This will involve the exploration of counter networks and the idea of hegemonic and ante-narrative (see Vickers, Beyond the hegemonic narrative – A study of managers. Journal of Organizational Change Management, 21, 560–573, 2008) This chapter will draw upon and inform Actor-Network Theory (Latour, The pasteurization of France. Cambridge, MA: Harvard, 1988; Latour, Reassembling the social – An introduction to actor-network-theory. Oxford: Oxford University Press, 2005; Callon, Some elements of a sociology of translation: Domestication of the scallops and the fishermen of Saint Brieuc Bay. In Law, J. (Ed.) Power, action and belief (pp. 196–233). London: Routledge and Kegan Paul, 1986; Law, On the methods of long‐distance control: Vessels, navigation and the Portuguese route to India. In Law, J. (Ed.) Power, action and belief (pp. 234–263). London: Routledge and Kegan Paul, 1984) in relation to HR and critical HR literature (Watson, HRM and critical social science analysis. Journal of Management Studies, 41 (3), 447–467, 2004; Delbridge and Keenoy, Beyond managerialism? International Journal of Human Resource Management, 21 (6), 799–817, 2010; Vickers and Fox, Towards practice-based studies of HRM: An actor network and communities of practice informed approach. International Journal of Human Resource Management, 21 (6), 899–914, 2010)

Simulating and predicting cellular and in vivo responses of colon cancer to combined treatment with chemotherapy and IAP antagonist Birinapant/TL32711

Apoptosis resistance contributes to treatment failure in colorectal cancer (CRC). New treatments that reinstate apoptosis competency have potential to improve patient outcome but require predictive biomarkers to target them to responsive patient populations. Inhibitor of apoptosis proteins (IAPs) suppress apoptosis, contributing to drug resistance; IAP antagonists such as TL32711 have therefore been developed. We developed a systems biology approach for predicting response of CRC cells to chemotherapy and TL32711 combinations in vitro and in vivo. CRC cells responded poorly to TL32711 monotherapy in vitro; however, co-treatment with 5-fluorouracil (5-FU) and oxaliplatin enhanced TL32711-induced apoptosis. Notably, cells from genetically identical populations responded highly heterogeneously, with caspases being activated both upstream and downstream of mitochondrial outer membrane permeabilisation (MOMP). These data, combined with quantities of key apoptosis regulators were sufficient to replicate in vitro cell death profiles by mathematical modelling. In vivo, apoptosis protein expression was significantly altered, and mathematical modelling for these conditions predicted higher apoptosis resistance that could nevertheless be overcome by combination of chemotherapy and TL32711. Subsequent experimental observations agreed with these predictions, and the observed effects on tumour growth inhibition correlated robustly with apoptosis competency. We therefore obtained insights into intracellular signal transduction kinetics and their population-based heterogeneities for chemotherapy/TL32711 combinations and provide proof-of-concept that mathematical modelling of apoptosis competency can simulate and predict responsiveness in vivo. Being able to predict response to IAP antagonist-based treatments on the background of cell-to-cell heterogeneities in the future might assist in improving treatment stratification approaches for these emerging apoptosis-targeting agents.</p