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Immediate Benefits Realized Following Implementation of Physician Order Entry at an Academic Medical Center
Mekhjian, Hagop S.
Kumar, Rajee R.
Kuehn, Lynn
Bentley, Thomas D.
Teater, Phyllis
Thomas, Andrew
Payne, Beth
Ahmad, Asif
Journal of the American Medical Informatics Association : JAMIA
Objective: To evaluate the benefits of computerized physician order entry (POE) and electronic medication administration record (eMAR) on the delivery of health care.
Design: Inpatient nursing units in an academic health system were the setting for the study. The study comprised before-and-after comparisons between phase 1, pre-implementation of POE (pre-POE) and phase 2, post-implementation of POE (post-POE) and, within phase 2, a comparison of POE and the combination of POE plus eMAR. Length of stay and cost were compared pre- and post-POE for a period of 10 to 12 months across all services in the respective hospitals.
Measurements: Comparisons were made pre- and post-POE for the time intervals between initiation and completion of pharmacy (pre-POE, n=46; post-POE, n=70), radiology (pre-POE, n=11; post-POE, n=54), and laboratory orders (without POE, n=683; with POE, n=1,142); timeliness of countersignature of verbal order (University Hospitals [OSUH]: pre-POE, n=605; post-POE, n=19,225; James Cancer Hospital (James): pre-POE, n=478; post-POE, n=10,771); volume of nursing transcription errors (POE with manual MAR, n=888; POE with eMAR, n=396); length of stay and total cost (OSUH: pre-POE, n=8,228; post-POE, n=8,154; James: (pre-POE, n=6,471; post-POE, n=6,045).
Results: Statistically significant reductions were seen following the implementation of POE for medication turn-around times (64 percent, from 5:28 hr to 1:51 hr; p<0.001), radiology procedure completion times (43 percent, from 7:37 hr to 4:21 hr; p<0.05), and laboratory result reporting times (25 percent, from 31:3 min to 23:4 min; p=0.001). In addition, POE combined with eMAR eliminated all physician and nursing transcription errors. There were 43 and 26 percent improvements in order countersignature by physicians in OSUH and James, respectively. Severity-adjusted length of stay decreased in OSUH (pre-POE, 3.91 days; post-POE, 3.71 days; p=0.002), but not significantly in James (pre-POE, 3.68 days; post-POE, 3.61 days; p=0.356). Although total cost per admission decreased significantly in selected services, it did not change significantly across either institution (OSUH: pre-POE, $5,697; post-POE, $5,661; p=0.687; James: pre-POE, $6,427; post-POE, $6,518; p=0.502).
Conclusion: Physician order entry and eMAR provided the framework for improvements in patient safety and in the timeliness of care. The significant cultural and workflow changes that accompany the implementation of POE did not adversely affect acuity-adjusted length of stay or total cost. The reductions in transcription errors, medication turn-around times, and timely reporting of results supports the view that POE and eMAR provide a good return on investment.
Related Articles
A Cross-site Qualitative Study of Physician Order Entry
Ash, Joan S.
Gorman, Paul N.
Lavelle, Mary
Payne, Thomas H.
Massaro, Thomas A.
Frantz, Gerri L.
Lyman, Jason A.
Journal of the American Medical Informatics Association : JAMIA
Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals.
Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data.
Measurements: Patterns and themes concerning perceptions of POE were identified.
Results: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions.
Conclusion: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.
Related Articles
Multiple perspectives on physician order entry.
Ash, J. S.
Gorman, P. N.
Lavelle, M.
Lyman, J.
Proceedings of the AMIA Symposium
OBJECTIVE: Describe the complex interplay of perspectives of physicians, administrators, and information technology staff regarding computerized physician order entry (POE) in hospitals. METHODS: Linstone's Multiple Perspectives Model provided a framework for organizing the results of a qualitative study done at four sites. Data from observation, focus groups, and formal and informal interviews were analyzed by four researchers using a grounded approach. RESULTS: It is not a simple matter of physicians hating POE and others loving it. The issues involved are both complex and emotional. All groups see both positive and negative aspects of POE. CONCLUSION: The Multiple Perspectives Model was useful for organizing a description to aid in understanding all points of view. It is imperative that those implementing POE understand all views and plan implementation strategies accordingly.
Related Articles
What's so special about medications: a pharmacist's observations from the POE study.
Carpenter, J. D.
Gorman, P. N.
Proceedings of the AMIA Symposium
Observations from a multi-site observational study of physician order entry (POE) confirm that implementing POE is problematic, and suggest that implementing medication order entry is particularly difficult. A pharmacist participating in the study group sought to answer the question: What makes medications different? Analysis of themes specific to medication POE in this study's large data set was undertaken using a grounded theory approach. Emerging themes in the data are explored and include: (1) order complexity and the consequences of error; (2) impacts on professional roles; (3) prescribing needs in different settings; and (4) technology impact on medication administration. Awareness of potential roadblocks and lessons learned from previous implementation attempts should help organizations considering medication POE to optimize their own strategies.
Related Articles
Perceptions of house officers who use physician order entry.
Ash, J. S.
Gorman, P. N.
Hersh, W. R.
Lavelle, M.
Poulsen, S. B.
Proceedings of the AMIA Symposium
OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process.
Related Articles
Physician Order Entry Or Nurse Order Entry? Comparison of Two Implementation Strategies for a Computerized Order Entry System Aimed at Reducing Dosing Medication Errors
Kazemi, Alireza
Fors, Uno GH
Tofighi, Shahram
Tessma, Mesfin
Ellenius, Johan
Journal of Medical Internet Research
Despite the significant effect of computerized physician order entry (CPOE) in reducing nonintercepted medication errors among neonatal inpatients, only a minority of hospitals have successfully implemented such systems. Physicians' resistance and users' frustration seem to be two of the most important barriers. One solution might be to involve nurses in the order entry process to reduce physicians' data entry workload and resistance. However, the effect of this collaborative order entry method in reducing medication errors should be compared with a strictly physician order entry method.
To investigate whether a collaborative order entry method consisting of nurse order entry (NOE) followed by physician verification and countersignature is as effective as a strictly physician order entry (POE) method in reducing nonintercepted dose and frequency medication errors in the neonatal ward of an Iranian teaching hospital.
A four-month prospective study was designed with two equal periods. During the first period POE was used and during the second period NOE was used. In both methods, a warning appeared when the dose or frequency of the prescribed medication was incorrect that suggested the appropriate dosage to the physicians. Physicians' responses to the warnings were recorded in a database and subsequently analyzed. Relevant paper-based and electronic medical records were reviewed to increase credibility.
Medication prescribing for 158 neonates was studied. The rate of nonintercepted medication errors during the NOE period was 40% lower than during the POE period (rate ratio 0.60; 95% confidence interval [CI] .50, .71;P < .001). During the POE period, 80% of nonintercepted errors occurred at the prescription stage, while during the NOE period, 60% of nonintercepted errors occurred in that stage. Prescription errors decreased from 10.3% during the POE period to 4.6% during the NOE period (P < .001), and the number of warnings with which physicians complied increased from 44% to 68% respectively (P < .001). Meanwhile, transcription errors showed a nonsignificant increase from the POE period to the NOE period. The median error per patient was reduced from 2 during the POE period to 0 during the NOE period (P = .005). Underdose and curtailed and prolonged interval errors were significantly reduced from the POE period to the NOE period. The rate of nonintercepted overdose errors remained constant between the two periods. However, the severity of overdose errors was lower in the NOE period (P = .02).
NOE can increase physicians' compliance with warnings and recommended dose and frequency and reduce nonintercepted medication dosing errors in the neonatal ward as effectively as POE or even better. In settings where there is major physician resistance to implementation of CPOE, and nurses are willing to participate in the order entry and are capable of doing so, NOE may be considered a beneficial alternative order entry method.
Medical order entry systems; decision support systems, clinical; medication erors; Iran; infant, newborn; patient safety
Related Articles
e-Health, m-Health and healthier social media reform: the big scale view
Bahagon, Yossi
Jacobson, Orit
International Journal of Integrated Care
In the upcoming decade, digital platforms will be the backbone of a strategic revolution in the way medical services are provided, affecting both healthcare providers and patients. Digital-based patient-centered healthcare services allow patients to actively participate in managing their own care, in times of health as well as illness, using personally tailored interactive tools. Such empowerment is expected to increase patients' willingness to adopt actions and lifestyles that promote health as well as improve follow-up and compliance with treatment in cases of chronic illness. Clalit Health Services (CHS) is the largest HMO in Israel and second largest world-wide. Through its 14 hospitals, 1300 primary and specialized clinics, and 650 pharmacies, CHS provides comprehensive medical care to the majority of Israel's population (above 4 million members). CHS e-Health wing focuses on deepening patient involvement in managing health, through personalized digital interactive tools. Currently, CHS e-Health wing provides e-health services for 1.56 million unique patients monthly with 2.4 million interactions every month (August 2011). Successful implementation of e-Health solutions is not a sum of technology, innovation and health; rather it's the expertise of tailoring knowledge and leadership capabilities in multidisciplinary areas: clinical, ethical, psychological, legal, comprehension of patient and medical team engagement etc. The Google Health case excellently demonstrates this point. On the other hand, our success with CHS is a demonstration that e-Health can be enrolled effectively and fast with huge benefits for both patients and medical teams, and with a robust business model.
CHS e-Health core components
They include:
1. The personal health record layer (what the patient can see) presents patients with their own medical history as well as the medical history of their preadult children, including diagnoses, allergies, vaccinations, laboratory results with interpretations in layman's terms, medications with clear, straightforward explanations regarding dosing instructions, important side effects, contraindications, such as lactation etc., and other important medical information. All personal e-Health services require identification and authorization.
2. The personal knowledge layer (what the patient should know) presents patients with personally tailored recommendations for preventative medicine and health promotion. For example, diabetic patients are push notified regarding their yearly eye exam. The various health recommendations include: occult blood testing, mammography, lipid profile etc. Each recommendation contains textual, visual and interactive content components in order to promote engagement and motivate the patient to actually change his health behaviour.
3. The personal health services layer (what the patient can do) enables patients to schedule clinic visits, order chronic prescriptions, e-consult their physician via secured e-mail, set SMS medication reminders, e-consult a pharmacist regarding personal medications. Consultants' answers are sent securely to the patients' personal mobile device.
On December 2009 CHS launched secured, web based, synchronous medical consultation via video conference. Currently 11,780 e-visits are performed monthly (May 2011). The medical encounter includes e-prescription and referral capabilities which are biometrically signed by the physician. On December 2010 CHS launched a unique mobile health platform, which is one of the most comprehensive personal m-Health applications world-wide. An essential advantage of mobile devices is their potential to bridge the digital divide. Currently, CHS m-Health platform is used by more than 45,000 unique users, with 75,000 laboratory results views/month, 1100 m-consultations/month and 9000 physician visit scheduling/month.
4. The Bio-Sensing layer (what physiological data the patient can populate) includes diagnostic means that allow remote physical examination, bio-sensors that broadcast various physiological measurements, and smart homecare devices, such as e-Pill boxes that gives seniors, patients and their caregivers the ability to stay at home and live life to its fullest. Monitored data is automatically transmitted to the patient's Personal Health Record and to relevant medical personnel.
The monitoring layer is embedded in the chronic disease management platform, and in the interactive health promotion and wellness platform. It includes tailoring of consumer-oriented medical devices and service provided by various professional personnel—physicians, nurses, pharmacists, dieticians and more.
5. The Social layer (what the patient can share). Social media networks triggered an essential change at the humanity 'genome' level, yet to be further defined in the upcoming years. Social media has huge potential in promoting health as it combines fun, simple yet extraordinary user experience, and bio-social-feedback. There are two major challenges in leveraging health care through social networks:
a. Our personal health information is the cornerstone for personalizing healthier lifestyle, disease management and preventative medicine. We naturally see our personal health data as a super-private territory. So, how do we bring the power of our private health information, currently locked within our Personal Health Record, into social media networks without offending basic privacy issues?
b. Disease management and preventive medicine are currently neither considered 'cool' nor 'fun' or 'potentially highly viral' activities; yet, health is a major issue of everybody's life. It seems like we are missing a crucial element with a huge potential in health behavioural change—the Fun Theory. Social media platforms comprehends user experience tools that potentially could break current misconception, and engage people in the daily task of taking better care of themselves.
CHS e-Health innovation team characterized several break-through applications in this unexplored territory within social media networks, fusing personal health and social media platforms without offending privacy. One of the most crucial issues regarding adoption of e-health and m-health platforms is change management. Being a 'hot' innovative 'gadget' is far from sufficient for changing health behaviours at the individual and population levels.
CHS health behaviour change management methodology includes 4 core elements:
1. Engaging two completely different populations: patients, and medical teams. e-Health applications must present true added value for both medical teams and patients, engaging them through understanding and assimilating "what's really in it for me". Medical teams are further subdivided into physicians, nurses, pharmacists and administrative personnel—each with their own driving incentive. Resistance to change is an obstacle in many fields but it is particularly true in the conservative health industry. To successfully manage a large scale persuasive process, we treat intra-organizational human resources as "Change Agents". Harnessing the persuasive power of ~40,000 employees requires engaging them as the primary target group. Successful recruitment has the potential of converting each patient-medical team interaction into an exposure opportunity to the new era of participatory medicine via e-health and m-health channels.
2. Implementation waves: every group of digital health products that are released at the same time are seen as one project. Each implementation wave leverages the focus of the organization and target populations to a defined time span. There are three major and three minor implementation waves a year.
3. Change-Support Arrow: a structured infrastructure for every implementation wave. The sub-stages in this strategy include:
Cross organizational mapping and identification of early adopters and stakeholders relevant to the implementation wave
Mapping positive or negative perceptions and designing specific marketing approaches for the distinct target groups
Intra and extra organizational marketing
Conducting intensive training and presentation sessions for groups of implementers
Running conflict-prevention activities, such as advanced tackling of potential union resistance
Training change-agents with resistance-management behavioural techniques, focused intervention for specific incidents and for key opinion leaders
Extensive presence in the clinics during the launch period, etc.
The entire process is monitored and managed continuously by a review team.
4. Closing Phase: each wave is analyzed and a "lessons-learned" session concludes the changes required in the modus operandi of the e-health project team.
e-Health; mobile health; personal health record; online visit; patient empowerment; knowledge prescription
Related Articles
The impact of physician order entry on nursing roles.
Weir, C.
Johnsen, V.
Roscoe, D.
Cribbs, A.
Proceedings of the AMIA Annual Fall Symposium
This study examines the impact of physician order entry (POE) on nurses perceptions of work, quality of care, and nurse/physician communication. Four hospitals that have implemented a computerized order-entry system with POE were compared with four similar hospitals using the same computerized system with clerk order entry only. Three factors were extracted from the 29 item survey using principal component extraction with varimax rotation that accounted for 16.5%, 12.4% and 8.7% of the variance respectively. Three scales were constructed from these factors measuring perceptions of impact of the information system on the quality of care, job, control, and nurse/physician communication. Nurses working in the POE environment rated their computer system as having greater impact on the quality of care and lower ratings of perceived control than those working in non-POE environments. No differences were found between nurses working in POE environments and those working in POE in terms of their ratings of frequency of contact and ease of access to physicians.
Related Articles
Implementation of physician order entry: user satisfaction and self-reported usage patterns.
Lee, F
Teich, J M
Spurr, C D
Bates, D W
Journal of the American Medical Informatics Association
OBJECTIVES: To evaluate user satisfaction, correlates of satisfaction, and self-reported usage patterns regarding physician order entry (POE) in one hospital. DESIGN: Surveys were sent to physician and nurse POE users from medical and surgical services. RESULTS: The users were generally satisfied with POE (mean = 5.07 on a 1 to 7 scale). The physicians were more satisfied than the nurses, and the medical staff were more satisfied than the surgical staff; satisfaction levels were acceptable (more than 3.50) even in the less satisfied groups. Satisfaction was highly correlated with perceptions about POE's effects on productivity, ease of use, and speed. POE features directed at improving the quality of care were less strongly correlated with satisfaction. The physicians valued POE's off-floor accessibility most, and the nurses valued legibility and accuracy of POE orders most. Some features, such as off-floor ordering, were perceived to be highly useful and reported to be frequently used by the physicians; while other features, such as "quick mode'' ordering and personal order sets, received little self-reported use. CONCLUSIONS: Survey of POE users showed that satisfaction with POE was good. Satisfaction was more correlated with perceptions about POE's effect on productivity than with POE's effect on quality of care. Physicians and nurses constitute two very different types of users, underscoring the importance of involving both physicians and nonphysicians in POE development. The results suggest that development efforts should focus on improving system speed, adding on-line help, and emphasizing quality benefits of POE.
Related Articles
Technology adoption and implementation in organisations: comparative case studies of 12 English NHS Trusts
Kyratsis, Yiannis
Ahmad, Raheelah
Holmes, Alison
BMJ Open
To understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process.
Qualitative, multisite, comparative case study design.
One primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control.
Participants and data analysis
121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning.
Main findings
Those involved in the process variably accessed three types of innovation knowledge: 'awareness' (information that an innovation exists), 'principles' (information about an innovation's functioning principles) and 'how-to' (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to 'how-to' compared with 'principles' knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption.
Potential adopters and change agents often overlooked or undervalued 'how-to' knowledge. Balancing 'principles' and 'how-to' knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready.
Article summary
Article focus
Despite policy support and the development of a dedicated evidence dissemination infrastructure in the NHS, why is technology adoption and implementation still a challenge?
We need to understand better how the innovation process unfolds in organisations to build on what we know about individual behaviours. In particular, how the use of different types of knowledge about an innovation impacts its adoption and implementation.
Key messages
In our study, centralised dissemination of evidence had minimal to moderate impact on organisational innovation adoption decisions. Practice-based, peer-mediated and local dissemination systems were perceived more relevant.
In contrast to technology adoption by individuals, organisational adoption required a wider multifaceted conceptualisation of 'how-to' knowledge in line with the more complex dynamics in organisations. When 'how-to' knowledge was undervalued and considered late, important strategic, structural and cultural elements of the trust's context were overlooked. This had negative implications for technology adoption and implementation.
Professional backgrounds of those involved in the process influenced the types of innovation knowledge considered, which had implications for implementation. The involvement of diverse professionals in decision-making improves the chances of successful implementation through a balanced consideration of the strength of scientific evidence and practical application.
Strengths and limitations of this study
The scale of the study, its real time and longitudinal nature provide a rich data set. Our study is theory driven and comprises multisite comparative case studies, which enhance the generalisability of findings beyond the context of the studied trusts.
We explicitly studied cases of non-adoption and discontinuation after initial adoption to provide important learning often missing from innovation diffusion research.
On limitations, we were not able to follow implementation past the end of August 2010 and therefore do not have information on routinised use of the implemented technologies.
Related Articles
Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa
Dickson, Kim E.
Tran, Nhan T.
Samuelson, Julia L.
Njeuhmeli, Emmanuel
Cherutich, Peter
Dick, Bruce
Farley, Tim
Ryan, Caroline
Hankins, Catherine A.
PLoS Medicine
Kim Dickson and colleagues analyze the progress made by 13 priority countries toward scale-up of medical male circumcision programs, finding that the most successful programs involve country ownership of the program and have sustained leadership at all levels.
Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date.
Methods and Findings
VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The "early adopter" countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers' Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program.
Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, more than 2.5 million people (mostly in sub-Saharan Africa) become infected with HIV, the virus that causes AIDS. There is no cure for HIV/AIDS and no HIV vaccine. Consequently, global efforts to combat HIV/AIDS are concentrating on evidence-based prevention strategies such as voluntary medical male circumcision (VMMC). Circumcision—the removal of the foreskin, a loose fold of skin that covers the head of the penis—reduced HIV transmission through sexual intercourse by 60% in men in trials undertaken in sub-Saharan Africa, so in 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended implementation of VMMC programs in countries with a generalized HIV epidemic and low levels of male circumcision. They also identified 13 countries in southern and eastern Africa as high priority countries for rapid VMMC scale-up. Mathematical modeling suggests that 20.3 million circumcisions by 2015 and 8.4 million circumcisions between 2016 and 2025 are needed to reach 80% VMMC coverage in these countries. If this coverage is achieved, it will avert about 3.4 million new HIV infections through 2025.
Why Was This Study Done?
Despite convincing evidence that VMMC is an effective, cost-saving intervention in the fight against HIV/AIDS, national VMMC scale-up programs in the priority countries are currently at very different stages. A better understanding of the challenges faced by these programs would help countries still in the early stages of VMMC scale-up implement their national programs and would facilitate implementation of other HIV prevention strategies. In this study, the researchers use the Diffusion of Innovations (DOI) theory to analyze progress towards VMMC scale-up in the priority countries and to identify the factors that may have expedited or hindered program scale-up. This theory seeks to explain how, why, and at what rate new ideas and technology spread through cultures. It posits that a few individuals ("innovators") adopt new ideas before they become mainstream ideas. A few more individuals—the "early adopters"—follow the innovators. The "early majority" is the next group to adopt the innovation, followed by the "late majority" and the "laggards."
What Did the Researchers Do and Find?
The researchers used the annual number of VMMCs performed in the priority countries since 2008 to classify the countries into DOI adopter categories. They calculated a total scale-up score for each country based on six key elements of program scale-up (such as whether and when a VMMC policy had been approved). Finally, they analyzed the association between the DOI adopter category and the scores for the individual scale-up elements to determine which elements predict adoption and VMMC scale-up. By the end of 2010, about 560,000 VMMCs had been completed, less than 3% of the target coverage for the priority countries. Kenya, the only DOI innovator country, had completed nearly two-thirds of the VMMCs needed to reach its target coverage and was the only country on track to reach its target. The early adopters (South Africa, Zambia, and Swaziland) had initiated VMMC program scale-up soon after the release of the 2007 recommendations and had started VMMC scale-up pilot programs in 2008 but were far from achieving their VMMC targets. Having a VMMC focal person, establishing a national policy, having an operational strategy, and establishing a pilot program all predicted early adoption of VMMC scale-up.
What Do These Findings Mean?
These findings show that, three years after the WHO/UNAIDS recommendation to integrate VMMC into comprehensive HIV prevention programs, VMMC scale-up activities had been initiated in all the priority countries but that progress towards the 80% coverage target was variable and generally poor. Importantly, they show that early adoption of VMMC as a national program had not necessarily resulted in rapid program scale-up. Although these findings may not be generalizable to other settings, they suggest that countries endeavoring to scale up VMMC (or other HIV prevention strategies) must not only be ready to adopt VMMC but must also ensure that all the factors critical to supporting and accelerating scale-up are incorporated into the scale-up program. Finally, these findings show that the most successful national programs are those that involve country ownership of the program and that have sustained leadership at all levels to facilitate the translation of research into national policies and programs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001133.
This study is part of a PLoS Collection of articles on VMMC (http://www.ploscollections.org/VMMC2011) and is further discussed in a PLoS Medicine Review Article by Hankins et al. (http://dx.doi.org/10.1371/journal.pmed.1001127)
Information is available from WHO, UNAIDS, and PEPFAR on all aspects of HIV/AIDS
NAM/aidsmap provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and information on male circumcision for the prevention of HIV transmission
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on aspects of HIV prevention, and on HIV/AIDS in Africa (in English and Spanish)
The Clearinghouse on Male Circumcision, a resource provided by WHO, UNAIDS, and other international bodies, provides information and tools for VMMC policy development and program implementation
Wikipedia has a page on Diffusion of Innovations theory (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Personal stories about living with HIV/AIDS are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
Related Articles
From policy to practice: implementation of physical activity and food policies in schools
Mâsse, Louise C
Naiman, Daniel
Naylor, Patti-Jean
The International Journal of Behavioral Nutrition and Physical Activity
Public policies targeting the school setting are increasingly being used to address childhood obesity; however, their effectiveness depends on their implementation. This study explores the factors which impeded or facilitated the implementation of publicly mandated school-based physical activity and nutrition guidelines in the province of British Columbia (BC), Canada.
Semi-structured interviews were conducted with 50 school informants (17 principals - 33 teacher/school informants) to examine the factors associated with the implementation of the mandated Daily Physical Activity (DPA) and Food and Beverage Sales in Schools (FBSS) guidelines. Coding used a constructivist grounded theory approach. The first five transcripts and every fifth transcript thereafter were coded by two independent coders with discrepancies reconciled by a third coder. Data was coded and analysed in the NVivo 9 software. Concept maps were developed and current theoretical perspectives were integrated in the later stages of analysis.
The Diffusion of Innovations Model provided an organizing framework to present emergent themes. With the exception of triability (not relevant in the context of mandated guidelines/policies), the key attributes of the Diffusion of Innovations Model (relative advantage, compatibility, complexity, and observability) provided a robust framework for understanding themes associated with implementation of mandated guidelines. Specifically, implementation of the DPA and FBSS guidelines was facilitated by perceptions that they: were relatively advantageous compared to status quo; were compatible with school mandates and teaching philosophies; had observable positive impacts and impeded when perceived as complex to understand and implement. In addition, a number of contextual factors including availability of resources facilitated implementation.
The enactment of mandated policies/guidelines for schools is considered an essential step in improving physical activity and healthy eating. However, policy makers need to: monitor whether schools are able to implement the guidelines, support schools struggling with implementation, and document the impact of the guidelines on students' behaviors. To facilitate the implementation of mandated guidelines/policies, the Diffusion of Innovations Model provides an organizational framework for planning interventions. Changing the school environment is a process which cannot be undertaken solely by passive means as we know that such approaches have not resulted in adequate implementation.
Physical education; Physical activity; Nutrition; School policies; School guidelines; Implementation; Uptake; Barriers; Facilitators; Qualitative
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Contrasting Views of Physicians and Nurses about an Inpatient Computer-based Provider Order-entry System
Weiner, Michael
Gress, Todd
Thiemann, David R.
Jenckes, Mollie
Reel, Stephanie L.
Mandell, Steven F.
Bass, Eric B.
Journal of the American Medical Informatics Association : JAMIA
Objective: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care.
Design: Survey.
Measurements: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses.
Results: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency.
Conclusion: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.
Related Articles
Principles for a Successful Computerized Physician Order Entry Implementation
Ash, Joan S.
Fournier, Lara
Stavri, P. Zoë
Dykstra, Richard
AMIA Annual Symposium Proceedings
To identify success factors for implementing computerized physician order entry (CPOE), our research team took both a top-down and bottom-up approach and reconciled the results to develop twelve overarching principles to guide implementation. A consensus panel of experts produced ten Considerations with nearly 150 sub-considerations, and a three year project using qualitative methods at multiple successful sites for a grounded theory approach yielded ten general themes with 24 sub-themes. After reconciliation using a meta-matrix approach, twelve Principles, which cluster into groups forming the mnemonic CPOE emerged. Computer technology principles include: temporal concerns; technology and meeting information needs; multidimensional integration; and costs. Personal principles are: value to users and tradeoffs; essential people; and training and support. Organizational principles include: foundational underpinnings; collaborative project management; terms, concepts and connotations; and improvement through evaluation and learning. Finally, Environmental issues include the motivation and context for implementing such systems.
Related Articles
Challenges to the implementation of International Health Regulations (2005) on Preventing Infectious Diseases: experience from Julius Nyerere International Airport, Tanzania
Bakari, Edith
Frumence, Gasto
Global Health Action
The International Health Regulations (IHR) (2005) is a legal instrument binding all World Health Organization (WHO) member States. It aims to prevent and control public health emergencies of international concern. Country points of entry (POEs) have been identified as potential areas for effective interventions to prevent the transmission of infectious diseases across borders. The agreement postulates that member states will strengthen core capacities detailed in the IHR (2005), including those specified for the POE. This study intended to assess the challenges faced in implementing the IHR (2005) requirements at Julius Nyerere International Airport (JNIA), Dar es Salaam.
A cross-sectional, descriptive study, employing qualitative methods, was conducted at the Ministry of Health and Social Welfare (MoHSW), WHO, and JNIA. In-depth interviews, focus group discussions (FGDs) and documentary reviews were used to obtain relevant information. Respondents were purposively enrolled into the study. Thematic analysis was used to generate study findings.
Several challenges that hamper implementation of the IHR (2005) were identified: (1) none of the 42 Tanzanian POEs have been specifically designated to implement IHR (2005). (2) Implementation of the IHR (2005) at the POE was complicated as it falls under various uncoordinated government departments. Although there were clear communication channels at JNIA that enhanced reliable risk communication, the airport lacked isolated rooms specific for emergence preparedness and response to public health events.
JNIA is yet to develop adequate core capacities required for implementation of the IHR (2005). There is a need for policy managers to designate JNIA to implement IHR (2005) and ensure that public health policies, legislations, guidelines, and practice at POE are harmonized to improve international travel and trade. Policy makers and implementers should also ensure that implementation of the IHR (2005) follow the policy implementation framework, particularly the contextual interaction theory which calls for the availability of adequate resources (inputs) and well-organized process for the successful implementation of the policy.
International Health Regulations (IHR) (2005); implementation; challenges; Port of Entry (POE); Tanzania
Related Articles
Considerations Regarding the Implementation of Computerized Physician Order Entry: Report of the Menucha Conference
Stavri, P. Zoe
Ash, Joan S.
Carpenter, James
Gibson, Richard
Kuperman, Gilad J.
Proceedings of the AMIA Symposium
Implementation of computerized physician order entry (POE) is being increasingly encouraged as an important solution to the challenge of medical error reduction. Use of POE is not widespread, however, in part because it has a reputation for being difficult to implement. To identify success factors for implementing POE, a consensus conference of invited experts holding multiple perspectives was convened near Portland, Oregon on May 10 and 11, 2001. At a retreat center called Menucha, experts from around the world met with members of the Oregon Health & Science University's Physician Order Entry Team (POET) of researchers for the purpose of developing recommendations for POE implementation. Funded by a research grant from the National Library of Medicine, the Menucha consensus conference succeeded in identifying a set of conditions that should exist prior to POE implementation, agreed on considerations for successful implementation, and a list of other considerations that fostered debate within the group and deserve further exploration.
Related Articles
Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations theory
Rahimi, Bahlol
Timpka, Toomas
Vimarlund, Vivian
Uppugunduri, Srinivas
Svensson, Mikael
BMC Medical Informatics and Decision Making
Computerized provider order entry (CPOE) systems have been introduced to reduce medication errors, increase safety, improve work-flow efficiency, and increase medical service quality at the moment of prescription. Making the impact of CPOE systems more observable may facilitate their adoption by users. We set out to examine factors associated with the adoption of a CPOE system for inter-organizational and intra-organizational care.
The diffusion of innovation theory was used to understand physicians' and nurses' attitudes and thoughts about implementation and use of the CPOE system. Two online survey questionnaires were distributed to all physicians and nurses using a CPOE system in county-wide healthcare organizations. The number of complete questionnaires analyzed was 134 from 200 nurses (67.0%) and 176 from 741 physicians (23.8%). Data were analyzed using descriptive-analytical statistical methods.
More nurses (56.7%) than physicians (31.3%) stated that the CPOE system introduction had worked well in their clinical setting (P < 0.001). Similarly, more physicians (73.9%) than nurses (50.7%) reported that they found the system not adapted to their specific professional practice (P = < 0.001). Also more physicians (25.0%) than nurses (13.4%) stated that they did want to return to the previous system (P = 0.041). We found that in particular the received relative advantages of the CPOE system were estimated to be significantly (P < 0.001) higher among nurses (39.6%) than physicians (16.5%). However, physicians' agreements with the compatibility of the CPOE and with its complexity were significantly higher than the nurses (P < 0.001).
Qualifications for CPOE adoption as defined by three attributes of diffusion of innovation theory were not satisfied in the study setting. CPOE systems are introduced as a response to the present limitations in paper-based systems. In consequence, user expectations are often high on their relative advantages as well as on a low level of complexity. Building CPOE systems therefore requires designs that can provide rather important additional advantages, e.g. by preventing prescription errors and ultimately improving patient safety and safety of clinical work. The decision-making process leading to the implementation and use of CPOE systems in healthcare therefore has to be improved. As any change in health service settings usually faces resistance, we emphasize that CPOE system designers and healthcare decision-makers should continually collect users' feedback about the systems, while not forgetting that it also is necessary to inform the users about the potential benefits involved.
Related Articles
The Effects of Creating Psychological Ownership on Physicians' Acceptance of Clinical Information Systems
Paré, Guy
Sicotte, Claude
Jacques, Hélène
Journal of the American Medical Informatics Association : JAMIA
Objective: Motivated by the need to push further our understanding of physicians' acceptance of clinical information systems, we propose a relatively new construct, namely, psychological ownership. We situated the construct within a nomological net using a prevailing and dominant information technology adoption behavior model as a logical starting point.
Design: A mail survey was sent to the population of users of a regional physician order entry (POE) system aimed at speeding up the transmission of clinical data, mainly laboratory tests and radiology examinations, within a community health network.
Measurements: All scales, but one, were measured using previously validated instruments. For its part, the psychological ownership scale was developed using a multistage iterative procedure.
Results: Ninety-one questionnaires were returned to the researchers, for a response rate of 72.8%. Our findings reveal that, in order to foster physicians' adoption of a clinical information system, it is important to encourage and cultivate a positive attitude toward using the new system. In this connection, positive perception of the technology's usefulness is crucial. Second, results demonstrate that psychological ownership of a POE system is positively associated with physicians' perceptions of system utility and system user friendliness. Last, through their active involvement and participation, physicians feel they have greater influence on the development process, thereby developing feelings of ownership toward the clinical system.
Conclusion: Psychological ownership's highly significant associations with user participation and crucial beliefs driving technology acceptance behaviors among physicians affirm the value of this construct in extending our understanding of POE adoption.
Related Articles
Clinical Team Functioning and IT Innovation: A Study of the Diffusion of a Point-of-care Online Evidence System
Gosling, A. Sophie
Westbrook, Johanna I.
Braithwaite, Jeffrey
Journal of the American Medical Informatics Association : JAMIA
Objectives: To investigate the association between clinical team functioning and diffusion (awareness, use, and impact) of a 24-hour online evidence retrieval system. To examine the relationships between clinical team characteristics and the adoption of the online evidence system.
Design: 18 clinical teams, consisting of 180 clinicians from three Australian hospitals, were identified and studied. Teams were categorized as small (≤ 15 members) or large (> 15).
Measurements: Clinical team functioning was assessed using the Team Climate Inventory (TCI). Awareness, use, and impact of an online evidence retrieval system were measured using a self-administered questionnaire. The relationships between TCI scores and awareness, use, and impact were examined using t-tests and one-way ANOVAs. Chi square analyses were used to examine differences between small and large teams. Results were interpreted within a diffusion of innovations framework.
Results: Clinical team functioning was not related to awareness or use of the online evidence retrieval system. However, clinical team functioning was significantly associated with the impact of online evidence in terms of reported experience of improved patient care following system use. Clinicians in small teams (≤ 15 members) had higher levels of system awareness compared to large (> 15) teams.
Conclusions: Team functioning had the greatest impact on the fourth stage of innovation diffusion, the effective use of online evidence for clinical care. This supports Rogers' diffusion of innovation theory, to the effect that different types of communication about an innovation are important at different stages in the diffusion process. Members of small teams were more aware of the system than members of large teams. Team functioning is amenable to improvement through interventions. The findings suggest that the role of team climate in the diffusion of information systems is a promising area for future research.
Related Articles
Controlled Trial of Direct Physician Order Entry
Overhage, J. Marc
Perkins, Susan
Tierney, William M.
McDonald, Clement J.
Journal of the American Medical Informatics Association : JAMIA
Objective: Direct physician order entry (POE) offers many potential benefits, but evidence suggests that POE requires substantially more time than traditional paper-based ordering methods. The Medical Gopher is a well-accepted system for direct POE that has been in use for more than 15 years. The authors hypothesized that physicians using the Gopher would not spend any more time writing orders than physicians using paper-based methods.
Design: A randomized controlled trial of POE using the Medical Gopher system in 11 primary care internal medicine practices.
Measurements: The authors collected detailed time use data using time motion studies of the physicians and surveyed their opinions about the POE system.
Results: The authors found that physicians using the Gopher spent 2.2 min more per patient overall, but when duplicative and administrative tasks were taken into account, physicians were found to have spent only 0.43 min more per patient. With experience, the order entry time fell by 3.73 min per patient. The survey revealed that the physicians believed that the system improved their patient care and wanted the Gopher to continue to be available in their practices.
Conclusions: Little extra time, if any, was required for physicians to use the POE system. With experience in its use, physicians may even save time while enjoying the many benefits of POE.
Related Articles
Rapid Deployment of Physician Order Entry using Web-Based, Disease-Specific Order Sets.
Windle, John
Van-Milligan, Glen
Duffy, Sean
McClay, James
Campbell, James
AMIA Annual Symposium Proceedings
Computerized physician order entry (POE) is a disruptive technology that holds great promise to reduce medical errors and improve workflow. However, Studies have reported significant physician resistance. We embarked on a two-pronged strategy to build broad support for POE: To build a secure, open source, browser-based platform to support POE and create a large number of disease-specific order-sets for immediate use. This presentation will demonstrate the conceptual framework and implementation requirements for such an endeavor.
Related Articles
Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory
Makowsky, Mark J
Guirguis, Lisa M
Hughes, Christine A
Sadowski, Cheryl A
Yuksel, Nese
Implementation Science : IS
In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists' adoption of prescribing using a model for the Diffusion of Innovations in healthcare services.
Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations.
Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists' adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists' decisions to apply for independent prescribing privileges.
Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists' adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists' prescribing behaviours.
Related Articles
The Impact of Computerized Physician Order Entry on Medication Error Prevention
Bates, David W.
Teich, Jonathan M.
Lee, Joshua
Seger, Diane
Kuperman, Gilad J.
Ma'Luf, Nell
Boyle, Deborah
Leape, Lucian
Journal of the American Medical Informatics Association : JAMIA
Background: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events.
Objective: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors.
Design: Prospective time series analysis, with four periods.
Setting and participants: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period.
Intervention: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings.
Main outcome measure: Medication errors, excluding missed dose errors.
Results: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001).
Conclusions: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.
Related Articles
Organizational Factors that Influence Information Technology Diffusion in Academic Health Sciences Centers
Ash, Joan
Journal of the American Medical Informatics Association
Abstract Objective: To identify the organizational factors which influence the diffusion of end user online literature searching, the computer-based patient record, and electronic mail systems in academic health sciences centers in the United States.
Design: A total of 1335 individuals working in informatics and library areas at 67 academic health sciences centers in the U.S. were surveyed. Multivariate techniques were used to evaluate the relationship between the set of six organizational factors and two measures of innovation diffusion.
Measurements: A Guttman-like scale was developed to measure infusion, or depth or sophistication, of each of the three innovations at each institution. Diffusion was measured by a question previously developed for another study. Six independent variables were measured via five formerly developed scales and one new one.
Results: The overall response rate was 41%. The set of organizational variables produced significant results in the diffusion of each of the three innovations, with individual variables influencing diffusion to varying degrees. The same set produced significant results in relation to infusion only for online searching. There was little or no correlation between infusion and diffusion for each innovation.
Conclusion: Organizational attributes are important predictors for diffusion of information technology innovations. Individual variables differ in their effect on each innovation. The set of attributes seems less able to predict infusion. It is recommended that both infusion and diffusion be measured in future studies because there is little relation between them. It is further recommended that individuals charged with implementing information technology in the health sciences receive training in managing organizational issues.
Related Articles
A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study
Bradley, Elizabeth H
Curry, Leslie A
Taylor, Lauren A
Pallas, Sarah Wood
Talbert-Slagle, Kristina
Yuan, Christina
Fox, Ashley
Minhas, Dilpreet
Ciccone, Dana Karen
Berg, David
Pérez-Escamilla, Rafael
BMJ Open
Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC.
To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs.
Data sources
We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites.
Study eligibility criteria, participants and interventions
We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the study's definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources.
Study appraisal and synthesis methods
We used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability.
The resulting model—the AIDED model—includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure to scale up may be attributable to insufficient assessment of user groups in context, lack of fit of the innovation with user receptivity, inability to address resistance from stakeholders and inadequate engagement with user groups.
The inductive approach used to construct the AIDED model did not allow for simultaneous empirical testing of the model. Furthermore, the literature may have publication bias in which negative studies are under-represented, although we did find examples of unsuccessful scale-up. Last, the AIDED model did not address long-term, sustained use of innovations that are successfully scaled up, which would require longer-term follow-up than is common in the literature.
Conclusions and implications of key findings
Flexible strategies of assessment, innovation, development, engagement and devolution are required to enable effective change in the use of family health innovations in LMIC.
Health Services Administration & Management; Health policy; International health services; Public Health; Scale up
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Schaumburg is a suburb of Chicago. With a population of approximately 75,000, Shaumburg provides a small town atmosphere while providing students with quick access to Chicago, only 30 miles away.
Nearby Chicago is a global city known for business, industry, and the arts. The city is located along Lake Michigan boasts 29 miles of lakefront that includes shops, condos, and parks. Outdoor enthusiasts enjoy the city's warm summers by visiting Lincoln Park and the Lincoln Park Conservatory or by relaxing beachside to Lake Michigan. The city is also a popular filming location for movie and television shows.
Schaumburg's proximity to the city allows sports fans easy access to games featuring the Chicago Bears, Chicago Blackhawks, Chicago Bulls, and Chicago Rush.
Major employers in Schaumburg include Motorola Solutions, IBM, Genworth Financial, Comcast, and Verizon Wireless.
The school opened in 1916 as The Commercial Art School, one of the country's first applied art and design schools. In the 1930s, the college became widely known as Ray-Vogue School, with programs in art and design. By 1991, the school moved to its Schaumburg location, and in 1995 joined The Art Institutes system of schools and was renamed The Illinois Institute of Art—Schaumburg.
The Illinois Institute of Art—Schaumburg prepares students for creative careers by providing opportunities to learn and grow while still in school. Students may attend a yearly trip abroad, a leadership retreat, or listen to sponsored speakers talking about art and community issues.
The school's hands-on education is supported by industry relevant computer labs, design labs, software, and equipment, including:
Many students choose to live in school-sponsored housing at Tree House Luxury Apartments of Versailles on the Lakes. Located close to the school, the apartments are fully furnished and have kitchens, fitness facilities, and common areas for students to gather.
To build relationships and gain experience in their areas of study, students participate in special events and workshops, join student groups, and work in internships within the Schaumburg area. The school also offers the following volunteer opportunities:

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A lifetime of service
Marshall F. McCallie looks back on diplomatic career
Published: Monday, January 1, 2007 at 4:30 a.m.
Last Modified: Monday, January 1, 2007 at 12:00 a.m.
Marshall F. McCallie, a retired Foreign Service career officer and former Ambassador to Namibia, moved to tranquil Transylvania County three years ago.
He and his wife Amye now spend leisure hours hiking and working for the Sierra Club and the Democratic Party. Marshall is current chairman of that county's Democratic Party and is up for reelection in the spring.
Born in Chattanooga, Tenn., McCallie had canoed and hiked through our mountains as a youth and spent many summers during his diplomatic career visiting family here with Amye and their two sons who attended Camp High Rock in Cedar Mountain.
"We were fortunate that in each of our five overseas posts we had American International schools and English was spoken, except our first assignment 1975-77 in Kinshasa, Zaire, (now the Democratic Republic of Congo) where we spoke French.
"My boys finished high school in Virginia when I was stationed back in Washington in the mid-80s. After their first day, I asked them how they liked it.
"They told me 'It was rather dull. In fact, they all look like us!' You see, their last school in Liberia had 32 different nationalities," McCallie said in a recent interview.
McCallie, 61, had majored in history and minored in French at Vanderbilt University, then spent four years as a communications electronics officer in the United States Air Force in Oklahoma City.
He believed a diplomat from the biggest power on earth should understand the military mind and the use of force. His interest in the foreign service was piqued as a youth by listening to missionaries talk about their time in Africa and by relating to many international students who came to live in his home.
"I remember my mother saying that she invited foreign students in to live with us in order to expose us to the world because she did not think we would ever get to travel far. It turned out my older brothers served in the Navy in Japan and my sister lived in Austria for years!"
After he left the Air Force, he earned two masters degrees at Fletcher School of Law and Diplomacy at Tufts University in Boston, followed by a job on the Peace Corps staff in Washington.
Ardent fans of that organization, Marshall and Amye later traveled often to the most rural parts of different African countries to visit and encourage Peace Corps teachers.
One second-generation Vietnamese American teacher of ninth and 10th grade math in Namibia had a doctorate in nuclear physics. He explained his choice to McCallie: "America gave me so much. Now I owe that to other countries."
When McCallie was appointed Ambassador to Namibia in 1993 he chose a female Peace Corps veteran as his second in command.
Of Africa's 52 countries McCallie served our State Department from 1975 to 2002 in five: Zaire political officer, Liberia political counselor, second in command at both Zambia and South Africa and Ambassador to Namibia. His one post outside Africa was as an economic officer in Abu Dhabi, the United Arab Emirates.
In addition, several Washington assignments included Nigeria Desk officer 1984-86 and special coordinator 1997-99 for the African Crisis Response Initiative, which meant working with the Defense Department toward peacekeeping training for African armies.
Although hers was not an easy task, Amye enjoyed working overseas with her husband, he added. Often all attention is paid to the career officer and the spouse is ignored.
"Amye kept busy teaching, helping in the libraries and working unpaid in the Ambassador Self Help program. That usually had about $10,000 to help build schools or brick factories or buy school uniforms.
"She went out to study the need for such things and either recommended it or not. She often went out with my driver into parts of the country where an accredited diplomat did not usually go, so she grew to know the community in wonderful ways."
Among requirements of an effective Secretary of State, McCallie includes first a clearly analytical mind. The individual should understand enough about American politics to know what the president can and can not do and should be able to empathize with people from other cultures and understand their interests during negotiations.
McCallie alluded to several recent Secretaries of State of both parties. "I think Kissinger (1973-77) was brilliant in terms of his overall grasp of history and foreign policy and diplomacy, and especially his strategic vision. That does not mean I would endorse all his recommendations country by country, though.
"I believe Cyrus Vance (1977-81) acted in the highest professional capacity when he told President Carter he would have to resign because he did not agree it was right to send men into Iran to rescue our hostages. He refused to resign ahead of time because that would have given away Carter's plans.
"Secretary George Schultz (1982-89) is a man I had a lot of respect for. I look at foreign policy from a nonpartisan standpoint and am perfectly willing to recognize Schultz. In fact, he kept President Reagan out of a lot of trouble.
"I have heard Schultz talk to incoming foreign service officers and he told them that he was interested in their ideas and would respect them, but they were his eyes and ears and they had to get him the facts. A secretary of state has to be a statesman, not a politician.
"Jim Baker (1989-92) is an operator in the best sense of the word. His work was crucial to building up the coalition for the First Gulf War. But I do not think President (George H. W.) Bush should have occupied Iraq then, nor should we have allowed Saddam during truce talks to keep his helicopters, which many think were later used to kill tens of thousands in the south.
"Colin Powell (2001-05) tried to warn President (George W.) Bush but his warnings were often not heeded. There was an enormous shift of weight in foreign policy from the State Department to the Defense Department and the office of Vice President Cheney, which was a recipe for disaster because Cheney and Rumsfeld had an ideological view of the world, and that blinds you to reality," McCallie said.
During his November talk before the Brevard chapter of NARFE (National Association of Active and Retired Federal Employees Association), McCallie said he considered it foolish when Iraq was so full of ethnic conflict and so unprepared for democracy, to go in there and ask for immediate elections.
"Instead we should have agreed it will take years to have greater stability, so first we should have worked for human rights, freedom of the press and people having access to lawyers if they get locked up.
"One of many ways (to practice good foreign policy) is to recognize the interests of other nations and not talk down to them like they were children," McCallie told 25 NARFE members and guests.
During December, several national television and newspaper columnists wondered what effect if any the Iraq Study Group Report would have on President Bush. Would he end up doing a U-turn in his policy there?
"Right now Bush remains committed to the notion of a unified Iraq. I will be very surprised if he does a U-turn, but I hope he will take the report seriously. I am half way through reading it myself," McCallie said on Dec. 14.
"I agree with what former Ambassador (to Croatia) Peter Galbraith said. He believes Iraq has reached the point when it will probably not see a solution short of federalism, with enormous autonomy in three separate regions. I would add there should be some agreement about sharing oil revenues three ways and that support from the powers surrounding the area is vital."
McCallie believes the idea would not be very popular with surrounding powers. The Turks, he said, would be uncomfortable with an independent Kurdistan. The Saudis would be enormously upset if the Sunni area is cut loose without resources, and it would be difficult for an independent Shi'a to maintain independence from Iran.
"America would have to become a facilitator in Iraq instead of continuing as sheriff!" said McCallie.
Freelancer Nancy Meanix lives in Transylvania County.
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Chipotle May Incur Fines After SEC Probe, Anderson Says
Chipotle Mexican Grill Inc. may incur legal fees or fines related to a U.S. Securities and Exchange Commission probe regarding work authorizations, said Stephen Anderson, an analyst at Miller Tabak & Co.
"There could be a fine of some sort" and "legal fees," Anderson, who is based in New York, said today in an interview. "I seriously thought this was something they put behind them."
Chipotle last week received a subpoena "requesting that we provide information regarding our compliance with employee work authorization requirements, our related public statements and other disclosures, and related information," the Denver-based company said in a May 18 SEC filing.
The SEC hasn't informed Chipotle as to the focus of its investigation, Chris Arnold, a company spokesman, said in an e-mail. John Nester, an SEC spokesman, declined to comment.
Chipotle rose 0.3 percent to $393.33 at the close in New York. The shares have gained 16 percent this year.
While the immigration investigation began in Minnesota in 2010, it has since spread to stores in Virginia and Washington, D.C. Last year, Chipotle said it was working with the U.S. Attorney's office in Washington, in addition to U.S. Immigration and Customs Enforcement, to provide certain documents as part of a review.
The 1,260-store burrito chain fired about 450 Minnesota workers who couldn't confirm the validity of their work documents. The firings affected store operations and resulted in a temporary increase in labor costs to train new workers, Chipotle said in a filing.
Labor Expenses
The additional labor expenses hurt 2011 profit by about 8 cents a share, Anderson said.
Chipotle, which provides language programs to help its restaurant workers learn English, has tried to promote store leaders from within its ranks. Almost 90 percent of salaried management and more than 95 percent of hourly managers come from internal promotions, according to a company filing.
Pei Wei Asian Diner, a restaurant chain owned by P.F. Chang's China Bistro Inc., was forced to temporarily close locations last year after losing unauthorized employees following an investigation. The closings hurt sales by about $1.1 million, the Scottsdale, Arizona-based company said in a filing.


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I'm creating a sproc that will insert rows into a 'staging' table with an insert into + subquery like so:
INSERT INTO myStagingTable
SELECT col1, col2, col3
FROM myRealTable
I need to put a conditional in there somehow to determine if the value from col1 for example already exists on myStagingTable, then don't insert it, just skip that row from myRealTable.
is this possible? If so, how would I structure that?


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updated 06/19/2012 AT 7:00 AM ET
•originally published 06/19/2012 AT 10:00 AM ET
Maddox, Pax, Zahara, Shiloh, Knox and Vivienne must be seeing their mom in a different light these days.
Donning horns, yellowed eyes and blood red lipstick, Angelina Jolie looks every bit the evil sorceress depicted in Disney's 1959 animated feature Sleeping Beauty.
In this updated version, the focus switches to the events that hardened Maleficent's heart, leading her to curse the baby Aurora (Sleeping Beauty), played by Elle Fanning.
Miranda Richardson, Juno Temple, Imelda Staunton and Sam Riley also star in this Wicked-like take on the classic fairy tale, which began filming in London on June 13 and is expected to run through the summer.
For the past couple of months, while the actress was in pre-production with the film, the Jolie-Pitts have made the U.K. their temporary home, stepping out for such family outings as a matinee performance of Billy Elliot and local playground visits.
Maleficent – in 3D – is scheduled to hit theaters March 14, 2014.


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The Harvard professor at the centre of the row with Blinkx has amended his controversial blog again after it was pointed out that one of his key points was wrong.
Ben Edelman, whose research triggered a 40pc slide in the online video company's shareprice, has withdrawn his assertion that Local Weather, a firm whose advertising practises he heavily criticised, was "part of Blinkx".
In his blog, the Darker Side of Blinkx, Prof Edelman said he had "grave doubts" about the Aim-listed company's revenues. When shortly afterwards, Prof Edelman amended his blog to dislose part of his research had been paid for by two anonymous US investors, speculation was fuelled that his clients were short-sellers.
Like YouTube, Blinkx allows users to search for and watch videos. The company also develops software that sits behind the content of other internet companies and helps them monetise it by generating targeted advertising.
In his blog, Prof Edelman argued that Blinkx had used "adware", or advertising software that promotes pop-ups and banners, to boost the views of its videos and inflate its income. He singled out Local Weather, a Minneapolis-based company that produces an application called Weather Alerts, for particular criticism as an example of a company with "deceptive" advertising practises.
Although he noted that Blinkx took "considerable steps to distance itself from these deceptive practices", he said his research had uncovered "factors [that] give good reason to conclude Local Weather is part of Blinkx."
However, The Daily Telegraph found that regulatory filings showed that Local Weather and Weather Alerts was part of a company called Weather Notifications which registered to Jon Coudron, a businessman based in Minneapolis. Mr Coudron, who said Mr Edelman had not contacted him, said: "I'm actually the owner of Weather Notifications, which is entirely owned by me, Blinkx has no ownership whatsoever." Mr Coudron said his companies use Blinkx software to power their advertising.
"It's very straight-forward Blinkx powers the software behind my ads," he said. "And I chose Blinkx because they have the best monetisation."
When Mr Coudron's ownership was pointed out to Prof Edelman, the academic amended his blog to say he has "good reason to conclude that Local Weather is applications are powered by Blinkx and part of the Blinkx network."
Prof Edelman stood by his suspicions. He told The Daily Telegraph: "The problem is the sneaky tactics Local Weather uses to get its software, and Blinkx adware, onto users' computers." Blinkx declined to comment.


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Party-whipping at the NDP/
Al-Masri Al-Youm reports that the NDP is about to discipline two of its MPs, who challenged Prime Minister Ahmad Nazif's speech in parliament.
The Arabist is published and edited by Issandr El Amrani, a writer and analyst based in Cairo, with contributions by friends.
The Arabist is a labor of love. We don't make much from ads, so please contribute to keep us going.
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First Nigerian-produced musical hits London's West End
- 22 July 2016
- From the section Entertainment & Arts
It was a hit in Lagos - and now it has come to London.
Wakaa The Musical follows the fate of a group of young graduates as they begin to find their way in the world.
The show aims to give audiences a taste of modern day Nigeria. It is the first Nigerian-produced musical to be performed at a London theatre.
I went to meet those behind the show as it opened in the West End.
Read full article First Nigerian-produced musical hits London's West End
Spielberg and Rylance's Big Friendly bromance
- 18 July 2016
- From the section Entertainment & Arts
"He's one of the greatest actors I've ever experienced in my career."
That's not a bad accolade for British actor, Mark Rylance, especially when it comes from one of Hollywood's biggest directors, Steven Spielberg.
Read full article Spielberg and Rylance's Big Friendly bromance
Georgia O'Keefe: Beacon of beauty and range
- 5 July 2016
- From the section Entertainment & Arts
In or around 1917 the notion that art should be beautiful was deemed passe. Marcel Duchamp had brought his homespun and highly persuasive cod French philosophy to Manhattan and declared that art should henceforth be "anti-retinal". He made his point with a "readymade" urinal.
The idea caught on and prevails to this day in the shape of unmade beds and rotting cows' heads. But not all artists swallowed Duchamp's ugly Parisian pill.
Read full article Georgia O'Keefe: Beacon of beauty and range
The quiet man at the British Museum
- 1 July 2016
- From the section Entertainment & Arts
When Neil MacGregor was the director of the British Museum, press conferences tended to be lively affairs. He was a born raconteur who'd make his points by telling stories and cracking jokes. He had the ability - like all natural showmen - to reach out to his audience.
His successor, Hartwig Fischer, is cast from a different mould. Three months into the job, and quite reasonably still sizing up the enormity of the task, he cuts a more circumspect figure. There were no laughs or stories or great statements about future plans at his press conference this morning. Instead, a gentle earnestness prevailed.
Venice Biennale's brighter future
- 29 May 2016
- From the section Entertainment & Arts
With thoughts on how to house Millenials and designs for an airport for drones, the visionary architects and curators at the Venice Architecture Biennale are looking to the future.
"If we're going to talk the talk, we have to walk the walk," insists the Pritzker Prize-winning Chilean architect Alejandro Aravena - curator of this year's Venice Architecture Biennale.
Turner Prize: Art not gibberish, please
- 12 May 2016
- From the section Entertainment & Arts
To start, a moan: why do the Turner Prize curators write such unintelligible gibberish about the artists shortlisted for the prize?
Where do they go to learn to produce these texts laden with pseudo-academic speak? Does their dense, mangled prose reflect a lack of confidence in the artists whose status and work - the curators' might think - needs to be elevated by arcane, pompous language?
Pushing the art of protest to new limits
- 28 April 2016
- From the section Entertainment & Arts
If you were going to use art as a form of protest, would you (a) drop an unannounced album on Tidal accompanied by a one-hour special on HBO, or (b) nail your genitals to a paving stone?
I (like you, I'm guessing) would go for A. But that's not an option. We are not Beyonce (when your name auto-corrects on Word, you know you've made it).
Conceptual art: What's the big idea?
- 26 April 2016
- From the section Entertainment & Arts
I'm down at Tate Britain and chatting to an old friend and half looking at a performance art thing happening in front of us when I realise we are the most attentive inattentive art-watchers at the early evening private view.
So, we weren't exactly concentrating on the choreographic goings-on central to Pablo Bronstein's newly unveiled performance installation, but at least we were giving it a respectful this-is-the-reason-for-all-the-free-hospitality glance.
Why is Shakespeare more popular than ever?
- 23 April 2016
- From the section Magazine
It's amazing, don't you think? Shakespeare is more popular today than he has been at any point since his death four centuries ago (there are no hard-and-fast stats to actually prove it, but the scholars to whom I have spoken all agree it is the case).
The Internet has played its part in the brand Bard propagation (Spark Notes, hem, hem), but it has also produced a mountain of alternative, more contemporary content upon which we could choose to feast. And yet it is Shakespeare who has risen to the top. And not just online where he's looked up so much that there are now bespoke Shakespeare search engines.
Read full article Why is Shakespeare more popular than ever?
Turner on the £20 note
- 22 April 2016
- From the section Entertainment & Arts
Artist JMW Turner and his painting The Fighting Temeraire will feature on the new design of the Bank of England's £20 note to enter circulation in 2020 - but is it a good choice?
I suppose if you were to choose the most influential British artist whose work resonates around the world and influenced a modern movement, you'd have to choose JMW Turner.


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Montegut woman dies after crash; driver injured
Published: Tuesday, December 15, 2009 at 9:24 a.m.
Last Modified: Tuesday, December 15, 2009 at 9:24 a.m.
CHAUVIN -— A Montegut woman was killed and a driver injured
Monday when their car hit an abandoned building on La. 56, authorities said.
Roy Leonard, 32, of Houma, was headed south on La. 56 about 4:15 a.m. when he crossed into the opposite lane of traffic and left the road, said trooper Bryan Zeringue, State Police Troop C spokesman. He said Leonard's 2004 Toyota Corolla hit a building in the 5500 block.
Leonard and his front-seat passenger, Virginia Newsome, 47, of Montegut, were taken to Chabert Medical Center in Houma. Newsome was later pronounced dead, Zeringue said. Leonard was taken to University Hospital in New Orleans, where he remained today with serious injuries.
Both wore seat belts. Alcohol is a suspected cause, Zeringue said, and blood was taken for testing. Zeringue said charges against Leonard are pending.
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Sateen Sunday: Take 15% off 1+ Yards of Organic Cotton Sateen Ultra fabric through 11:59 p.m. EDT July 24th.
I am a K-8 art teacher, a painter, and a collage artist as well as a designer. Some of my drawings, paintings, and collage are posted on my DeviantArt site (link below).
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