Complexity and the science of implementation in health IT—Knowledge gaps and future visions

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Abstract

Objectives

The intent of this paper is in the examination of health IT implementation processes – the barriers to and facilitators of successful implementation, identification of a beginning set of implementation best practices, the identification of gaps in the health IT implementation body of knowledge, and recommendations for future study and application.

Methods

A literature review resulted in the identification of six health IT related implementation best practices which were subsequently debated and clarified by participants attending the NI2012 Research Post Conference held in Montreal in the summer of 2012. Using the framework for implementation research (CFIR) to guide their application, the six best practices were applied to two distinct health IT implementation studies to assess their applicability.

Results

Assessing the implementation processes from two markedly diverse settings illustrated both the challenges and potentials of using standardized implementation processes. In support of what was discovered in the review of the literature, “one size fits all” in health IT implementation is a fallacy, particularly when global diversity is added into the mix. At the same time, several frameworks show promise for use as “scaffolding” to begin to assess best practices, their distinct dimensions, and their applicability for use.

Conclusions

Health IT innovations, regardless of the implementation setting, requires a close assessment of many dimensions. While there is no “one size fits all”, there are commonalities and best practices that can be blended, adapted, and utilized to improve the process of implementation. This paper examines health IT implementation processes and identifies a beginning set of implementation best practices, which could begin to address gaps in the health IT implementation body of knowledge.

Section snippets

Introduction and review of the literature

Deploying new technology and practice innovations in complex healthcare environments is challenging, particularly when the innovation is disruptive to established structures and workflow. Electronic health record systems (EHRS) and/or other types of health information technology (IT) are considered disruptive technologies, and their integration into practice has been slow and problematic. Even in light of numerous reports of the benefits of EHRS, when evidence meets the realities of practice [1]

Methods and approach: Best practices in HIT implementation – beginning steps

Since implementation science in general has been considered by many to be in its infancy, the lack of literature found that discusses implementation science within the context of health IT is not surprising, yet is presented a challenge for the identification and application of best practices in HIT implementation. As implementation science continues to evolve and its application in health IT interventions increases – there will be a concomitant growth of the knowledge base of proven models,

Results

In the sections below, two HIT implementation case studies are first described and are then evaluated relative to the best practices identified in Table 1 as a demonstration. In the discussion section, barriers and facilitators to successful HIT implementation are described and recommendations are made for overcoming barriers, strengthening facilitators and increasing the probability of implementation success. The case studies highlight the multiple challenges faced in HIT implementation in

Discussion

The two case studies presented originate from two markedly different situations. This illustrates the challenges highlighted in the literature regarding the use of standardized implementation processes. “One size fits all” in health IT implementation is a fallacy particularly when global diversity is added into the mix. However, several frameworks have been presented that can be used as a scaffolding to begin to assess best practices, their distinct dimensions, and their applicability for use.

Summation

The presentation, analysis and discussion illustrated that the nascent six implementation best practices and the CFIR were acceptable structures for assessing certain aspects of the case studies. There is much work left to be done, not only in gaining a deeper understanding of implementation processes, but also in developing a scaffold or method for beginning to analyze EHRS implementations as we have begun. Interesting findings emerged from both, and using the scaffold (Table 1) assisted us in

Conclusion

Adoption of electronic systems and other health IT innovations into complex healthcare environments has been slow and problematic. Recent work in implementation science suggests that both the technology and the implementation process must be addressed when implementing health IT innovations. This paper examined health IT implementation processes and identified a beginning set of implementation best practices, which if used consistently, could begin to address gaps in the health IT

Author contributions

Patricia Abbott is the lead author who organized submission, managed the project, wrote significant portions of the paper, participated in editing, participated in development of paper framework/grid and identification of six best practices, and submitted the paper. Jo Foster, Patricia Dykes and Heimar de Fatima Marin contributed in writing/summarizing one of the two case studies, editing, participating in identification of six best practices, participating in development of paper

Conflict of interest

There are no conflicts of interest noted from any of the authors on this paper.

Summary points

What is already known?

  • There is more than evidence needed for successful adoption, implementation and sustainability of health IT.

  • There is a pressing need for better understanding of what works, what does not, and in what context.

  • Mixed models and mixed methods may work best for implementation interventions.

What does this study add?

  • A beginning set of literature supported and transferrable implementation

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