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Establishing evidence-based practice is a difficult process. The authors describe an innovative collaborative project for establishing evidence-based practice in managing pain in pediatric oncology patients. Using the project as an example, they address the theoretical foundation to support evidence-based practice, barriers to adopting evidence, and strategies for overcoming barriers.
This article will concern itself with 3 ethical challenges that are special to the role of the surgeon in our society. First is the teaching of surgery. This might be called "performing an operation for the first time (for the individual surgeon)." Second is surgical innovation. This might be termed "performing a new operation for the first time ever." The third ethical challenge is the role of the surgeon in managed care. This might be stated as "Can we trust corporations to provide all-risk coverage and freedom in clinical decisions?"
Mayo Clinic has a long-standing reputation as a leader in the basic and clinical sciences. However, there is little in the published literature about Mayo Clinic's contributions to the delivery of health care services. This article is an overview of what Mayo brought to health care delivery between the 1860s and the 1980s, highlighting some of the lesser-known innovations that have influenced health care delivery on a national and international level such as the development of group practice and medical specialties, the creation of medical records, the use of allied health care providers, and facility design.
Health care institutions are considering a variety of emerging information technologies (ITs) in the hope of increasing efficiency, reducing costs, re-engineering work processes, and improving quality of care. The recent, rapid advances made in the use of innovative ITs in the health care field can present a plethora of problems to the administrative staff. Perhaps the most pressing of these concerns is the ability of today's hospitals to effectively create and utilize computer-based information systems. IT implementation has long been of great interest for information systems researchers. This branch of information system study seeks to identify those factors that are integral to optimizing the usage of IT. For example, researchers have advised practitioners that managerial support, high quality system design, commitment to advancing with the field, and extensive project planning are all key elements of successful system. In sum, previous research has produced a set of managerial proscriptions which, taken as a whole, constitute the "ideal" way to implement an IT system. Yet despite these normative principles and proscriptions, many health care institutions continue to find their attempts to make use of IT fraught with difficulty. Therefore, the objective of this study is to broaden and edify our understanding of IT implementation. More specifically, we seek to dispel the myth of the "ideal" system setup by exploring some of the alternative systems in use. We wish to investigate how and why the components of these alternative systems interact to produce utilization success (or failure). The study investigates the establishment and subsequent use of three clinical information systems (CIS) in a large tertiary care teaching hospital. The first case study is that of the hospital-wide implementation of a computer system that allows physicians to sign their medical records electronically. The second case examines the use of an electronic patient chart used to support the work of a variety of clinicians. Finally, we study a nursing assessment system used by two groups of nurses (intensive care unit and resuscitation unit) at a state-of-the-art, newly established Trauma Center. Qualitative was gathered through semi-structured interviews with people involved in the implementation process as well as a sample of user representatives. More than 90 interviews were conducted over a period of six months. Observational data completed our qualitative assessment. Quantitative evidence was gathered through questionnaires administered to a small sample of key informants. Three techniques of qualitative data analysis are being used in combination, namely, coding, analytical memos and displays. Data analysis is still in its infancy at this point. Regarding its relevance to the role of the administrator, this study will allow general and health care management as well as IT professionals to gain insight into the dynamics of the implementation of innovative technologies. In other words, results from this study will provide clear and relevant answers to the questions of how and why the outcome of the information system project is influenced by the way in which the technology is introduced.
The German "GKV-Modernisierungsgesetz" offers new opportunities for patient care. The concept of "integrated care" provides organizational structures for an standardized treatment of myocardial infarction by bridging the different sectors of the German health care system. Apart from guideline-based therapy, innovative diagnostic (cardiac MRI) and therapeutic (drug-eluting stents) techniques are implemented in the "integrated care" model as well. The "Herzinfarktverbund Essen" is the first national real world experience of the integrated care concept in the treatment of myocardial infarction.
Over the past thirty-five years, U.S. age-adjusted mortality from cardiovascular disease declined 50 percent. This marked reduction reflects advances in the prevention, diagnosis, and treatment of common cardiovascular conditions. Pharmaceutical agents play a major role in prevention of atherosclerosis and its consequences: heart attack, stroke, and heart failure. Additionally, novel device-based therapies contribute to the decline in cardiac morbidity and mortality. Whereas innovative strategies based on accurate imaging of the heart and blood vessels are implemented widely now, hope exists that lifestyle changes, early risk-factor screening, and more efficacious drugs will strikingly reduce cardiovascular disease in the future.
The Veterans Health Administration (VHA) in the US Department of Veterans Affairs (VA) manages the largest fully integrated health care system in the United States. In 1995, the VHA initiated a reinvention effort that included the most radical redesign of VA health care to occur since the veterans health care system was formally established in 1946. The 2 paramount goals of this reinvention effort were to ensure the predictable and consistent provision of high-quality care everywhere in the system and to optimize the value of VA health care. Although still a work in progress, dramatic results have been achieved toward these ends during the past 5 years. This article provides an overview of the veterans health care system, and it highlights selected aspects of the system's reengineering. It also describes various steps that have been taken to better manage performance and to systematize quality improvement and quality innovation. This information provides a global context that should facilitate understanding of the genesis and purposes of the Quality Enhancement Research Initiative that is described in other articles in this issue of Medical Care.
Human implant technologies are subject to continual innovation and proliferation, raising important issues for technology testing, healthcare sciences, clinical performance and risk assessment, and regulation. The regulatory environment of medical devices is being shaped by harmonisation of standards in the European Union. The aim of this paper is to compare the histories and current regulatory environment of two technologies, breast implants and artificial hips, and to consider the implications of this comparison for a sociological healthcare research agenda to investigate the issues raised. The main focus is upon developments in the United Kingdom. Major points of contrast between the two technologies include the institutional contexts in which clinical evidence has been marshalled for government attention; the relative importance of strategic alliances between clinicians and manufacturers in the innovation process; the degree of public controversy evident; the varying definitions of an 'adverse incident' within medical device vigilance systems; and in the UK the presence of a national register for breast implants but not for hip implants. Inter-national contrasts in these dimensions are noted. The analysis suggests that improved understanding is required of the institutional, organisational and professional processes involved in implant technology innovation and regulation. A comparative research agenda is proposed, focusing upon: innovativeness and proliferation; safety and technological standards; clinical and social outcomes; and consumer/user information and choice. It is concluded that research in these areas will enhance the 'evidence-base' for the evaluation of human implant technologies in the context of their innovatory and regulatory environments.
The Intervention Wheel is a population-based practice model that encompasses three levels of practice (community, systems, and individual/family) and 17 public health interventions. Each intervention and practice level contributes to improving population health. The Intervention Wheel, previously known as the Public Health Intervention Model, was originally introduced in 1998 by the Minnesota Department of Health, Section of Public Health Nursing (PHN). The model has been widely disseminated and used throughout the United States since that time. The evidence supporting the Intervention Wheel was recently subjected to a rigorous critique by regional and national experts. This critical process, which involved hundreds of public health nurses, resulted in a more robust Intervention Wheel and established the validity of the model. The critique also produced basic steps and best practices for each of the 17 interventions. Part I describes the Intervention Wheel, defines population-based practice, and details the recommended modifications and validation process. Part II provides examples of the innovative ways that the Intervention Wheel is being used in public health/PHN practice, education, and administration. The two articles provide a foundation and vision for population-based PHN practice and direction for improving population health.
An organization devoted to the support of small-to-medium-sized companies in the medical technology sector has recently been established in the United Kingdom. Medilink is a non-profit-making association that assists manufacturers in product development and marketing. This article discusses how it can generate new business opportunities for companies and the importance it places on establishing links.
This article explores the gap that currently exists between nursing research and nursing practice. The aim is to promote the conversion of new knowledge into practical innovations. Barriers to research utilization in practice settings come from both the academic and clinical arenas. Innovative models and strategies are needed to overcome these barriers. The purposes and value of research utilization and the clinical and academic strategies that facilitate research are discussed. Supporting clinical studies are provided as exemplars.
In order to improve documentation, a home health agency task force analyzed and revised its current nursing care plan system. Nurses in the five-county service area were involved in all aspects of the development. The system combines nursing interventions and patient outcomes with the overall physician plan to generate a totally computerized treatment plan.
Medical technologies that have high initial and operating costs are commonly labeled 'Big Ticket Technologies'. However, technologies with lower initial and operating costs, but which are utilized extensively in patient care, should be considered Big Ticket as well. Some of these technologies are product innovations, because they represent a new product or service. Others are process innovations because they provide an alternative way of delivering health care. Radiology and radiation oncology offer many examples of Big Ticket technologies in medicine, including CT scanners, MRI units and linear accelerators. Other examples include extracorporeal shock wave lithotripsy and resuscitation and intensive care technologies. Differences in the availability of these technologies in various countries reflects financial incentives and disincentives at work in the countries, expectation levels for health care in the countries, and the degree to which the diffusion and use of medical technologies are regulated. Evidence of the cost-effectiveness of medical technologies, and the impact of their use on health outcomes, is rapidly being added as an additional criterion for evaluation of the usefulness of medical technologies in health care.
In summary, EAST is a very different organization today than it was 12 years ago when it was conceived in the lounge of the Washington airport. It started as a traditional scientific organization, but an organization with a very different mission. Its mission was to identify and nurture the young traumatologist and to provide that individual with the opportunity for academic advancement. The EAST of the next millennium will be different still. The new EAST will reside on the Internet. It will provide a creative forum for scientific content, educational content, and practice content. It will adjudicate that content rapidly, equitably, and educationally. It will disseminate that content to the membership, to the trauma community, and to the community at large. It will encourage discourse, the exchange of ideas, the exchange of data, and the exchange of content. Finally, EAST will continue to meet the challenge of creating new and innovative products to foster the career of young trauma surgeons worldwide. Will the new world be complex? Yes. Will it be possible to drown in information? Yes. Will EAST meet those challenges head on? Yes. Will we succeed? Yes. We will succeed because we will remember the mission.
Technological innovations sometimes compel paradigm shifts. Two decades ago the CT scanner was one such phenomenon: It quickly and absolutely transformed medical practice. A marriage of medicine and telecommunications could engender a similar transformation. The timing surely is favorable, as pressing requirements of healthcare reform coincide with the flowering of telecommunications technologies.
The process by which administrators, physicians, and other health professionals develop decisions on the adoption of innovations was examined through a study of the decision process relating to the institutional use of a vaccine to prevent hepatitis B. Mail questionnaires and telephone follow-up interviews were used to collect data on the decision process in 56 Arizona hospitals in 1983 and 1984. A five-stage decision process was employed by the institutions. Critical stages in the process involved defining who would make the adoption decision and the collection of information related to the innovation. The institutional plans for vaccine distribution did not exhibit a clear consensus regarding the identification of high-risk employee groups. Employee acceptance of the vaccine, even with the cost paid by the hospital, was limited.
This article reviews progress in the diagnosis of breast lesions, focusing on improvements in breast biopsy. Both surgical and stereotactic biopsy techniques are discussed, as well as some of the latest methods incorporating computer-aided digital display. Finally, a new method for sampling breast lesions, the Mammotome biopsy system, is described and evaluated.
A decision-making model developed by two nursing administrators provides quality service using participatory, innovative managerial techniques. Treating the front-line service providers as clients proved to be the best way to develop a case management service for the ultimate client--the patient. Encouragement, respect and empowerment led to the formation of regional coalitions under one agency leadership.