We are bitter, but we are better off: Case study of the implementation of an electronic health record system into a mental health hospital in England

In contrast to the acute hospital sector, there have been relatively few implementations of integrated electronic health record (EHR) systems into specialist mental health settings. The National Programme for Information Technology (NPfIT) in England was the most expensive IT-based transformation of public services ever undertaken, which aimed amongst other things, to implement integrated EHR systems into mental health hospitals. This paper describes the arrival, the process of implementation, stakeholders' experiences and the local consequences of the implementation of an EHR system into a mental health hospital

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

The experience of implementing the board of trustees� policy in teaching hospitals in Iran: An example of health system decentralization

Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals� financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees� policy did not achieve its perceived objectives. Methods: We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran�s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach. Results: Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals� organization and capacity and actors� interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account. Conclusion: The implementation of the board of trustees� policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran�s health system. © 2015 by Kerman University of Medical Sciences

The rise and fall of an empire: critical reflections on the National Programme for IT in England

This presentation was given as part of the Health Studies and Community Health Division Seminar Series 2011-12 by Dr Amir Takian from the School of Health Sciences and Social Care at Brunel University on the 8th December 2011. Prior to joining Brunel as a Lecturer of Health Policy in the School of Health Sciences and Social Care, Dr Takian was a Research Fellow in the Department of Practice and Policy in the School of Pharmacy at the University of London

Monolithic integration of broadband optical isolators for polarization-diverse silicon photonics

Integrated optical isolators have been a longstanding challenge for photonic integrated circuits (PIC). An ideal integrated optical isolator for PIC should be made by a monolithic process, have a small footprint, exhibit broadband and polarization-diverse operation, and be compatible with multiple materials platforms. Despite significant progress, the optical isolators reported so far do not meet all these requirements. In this article we present monolithically integrated broadband magneto-optical isolators on silicon and silicon nitride (SiN) platforms operating for both TE and TM modes with record high performances, fulfilling all the essential characteristics for PIC applications. In particular, we demonstrate fully-TE broadband isolators by depositing high quality magneto-optical garnet thin films on the sidewalls of Si and SiN waveguides, a critical result for applications in TE-polarized on-chip lasers and amplifiers. This work demonstrates monolithic integration of high performance optical isolators on chip for polarization-diverse silicon photonic systems, enabling new pathways to impart nonreciprocal photonic functionality to a variety of integrated photonic devices

Influence of organizational culture on provider adherence to the diabetic clinical practice guideline: using the competing values framework in Palestinian Primary Healthcare …

Background Diabetes mellitus (DM) is a serious chronic disease and an important public health issue. This study aimed to identify the predominant culture within the Palestinian Primary Healthcare Centers of the Ministry of Health (PHC-MoH) and the Primary Healthcare Centers of the United Nations Relief and Works Agency for Palestine Refugees (PHC-UNRWA) by using the competing values framework (CVF) and examining its influence on the adherence to the Clinical Practice Guideline (CPG) for DM. Methods A cross-sectional design was employed with a census sample of all the Palestinian family doctors and nurses (n= 323) who work within 71 PHC clinic. A cross-cultural adaptation framework was followed to develop the Arabic version of the CVF questionnaire. Results The overall adherence level to the diabetic guideline was disappointingly suboptimal (51.5%, p< 0.001; 47.3% in the PHC-MoH and 55.5% in

Control of antimicrobial resistance in Iran: The role of international factors

Background: Antimicrobial resistance (AMR) is currently causing various challenges for all countries around the world. Accordingly, the WHO is placing a great emphasis on the global partnership and allinaces to drive countries towards developing policy guidances and a strategic framework for AMR contatiment. This study thus seeks to elaborate on the international factors underlying AMR management in Iran. Methods: Semi-structured interviews were conducted with managers from the Ministry of health (n = 14), Iran veterinary organization (n = 4), the national professional associations (n = 3) and researchers (n = 3), between November 2018 and July 2019. Participants were selected using purposeful and snowball sampling. Interviews were recorded and transcribed verbatim and were subsequently coded and analyzed thematically using MAXQDA software (V.18) and reported. Results: International enabling and predisposing factors were identified in relation to the AMR control in the country. Enabling factors included knowledge transfer, facilitation in policy agenda setting, formulation and implementaion process, and AMR monitoring. Predisposing factors, alternatively, encompassed the migration of infectious patients, trafficking of medicine and livestock from neighboring countries, and the imposed sanctions. Conclusion: Nowadays, AMR is taken cognizance of as a global challenge, thus to be addressed effectively, needs an international consensus more than ever. This harmony would not certainly underrate national efforts, but instead, is needed to reinforce such efforts through e.g. technical and financial assistance. It is suggested for policymakers to use all available political and legal means such as health diplomacy to establish humanitarian channels in order to enhance global convention and remove possible barriers as the sanctions and reduce their adverse consequences for AMR control. © 2020 The Author(s)

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems

Background: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments’ healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. Methods: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England’s National Health Service’s Care Records Service (NHS CRS). Results/discussion: We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. Summary: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries

Evidence from the decade of action for road safety: a systematic review of the effectiveness of interventions in low and middle-income countries

Objectives: To evaluate the effectiveness of road safety interventions in low and middle-income countries (LMICs), considering the principles of systems theory presented in the Global Plan for the Decade of Action for Road Safety. Methods: We conducted a systematic review according to PRISMA guidelines. We searched for original research studies published during 2011–2019 in the following databases: Medline, Embase, PsycInfo, Scopus, Web of Science, Cochrane library, Global Health Library, ProQuest and TRID. We included studies conducted in LMICs, evaluating the effects of road traffic safety interventions and reporting health-related outcomes. Results: Of 12,353 non-duplicate records, we included a total of 33 studies. Most interventions were related to legislation and enforcement (n = 18), leadership (n = 5) and speed management (n = 4). Overall, legislation and enforcement interventions appear to have the largest impact. Few studies were found for road infrastructure, vehicle safety standard and post crash response interventions. Conclusion: Based on the currently available evidence, legislation and enforcement interventions appear most impactful in LMICs. However, many interventions remain understudied and more holistic approaches capturing the complexity of road transport systems seem desirable. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197267, identifier CRD42020197267

Fail to prepare and you can prepare to fail: The experience of financing path changes in teaching hospitals in Iran

Background: In 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called "hospital autonomy" policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals' performance, hoping to reduce government's costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings. Methods: We conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach. Results: We found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals' organization, feasibility of policy implementation, actors and stakeholders' support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure. Conclusions: Autonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result. © 2016 Doshmangir et al