In hindsight, what would you have done differently? Comments:

We should have formalised it (outcomes) Should have purged (cleaned) it before starting maybe better education

Should have done it sooner! More publicity!

Summary and Outcomes of systems Outcomes

This fourth section of results revealed the importance and the justification for adding an outcomes element in the implementation cycle. As well as the need to formalise data feedback back to the practice in their multiple forms.

Of encouragement was the minimal disruption to practice life after the introduction of an information system to support the prevention and management of chronic conditions. Perhaps as was later mentioned, this was due to the ‘easiness’ of the system implemented and the on-demand training and support that they had from the Division IM/IT program. The lack of emerging new issues throughout the interviews and in the final comments section lends itself to suggest that the structured interviews covered most of the key issues of interest in this framework, mostly due to the success of the exploratory pilot interviews to explore the emerging framework in comprehensive detail before the actual data

collection.

Overall Summary

The analysis of the first data collection suggested that some changes are needed to the emerging framework. The benefit of having been involved in the practical implementations in these settings before the study, will help provide an insider’s interpretation of the data collected to modify the framework in light of the findings. The three main sections and their modifications will be now summarised.

Alteration to the framework

This section discusses how the emerging framework can be altered to become a more robust framework in light of the findings of this first data collection section.

In the first instance and from the previous results, it can be inferred that there is a distinct divide between the standard motivators for change (financial, accreditation, special interest, government influence, patient needs, among others); and the more prominent ‘awareness’ that defines the chronic condition problem in their own practices. The central and distinct element here was “patient care”. This awareness was shown to be the product of a purposeful ‘Problem Definition’ stage within the processes through which these practices travelled. The major influences in this process are well documented in the data collected; mainly the Division IT/IM support program (external influence); and the practice champion (internal influence) searching through the practice database to find this evidence.

These differences are amended in the upgraded framework, as originally the problem definition stage was assumed to take place later in the framework process. In essence, this finding places the problem definition element as the main influence on highlighting the evidence (such as: the low rate of females being screened at the practice) for creating

awareness of the gaps in care. This situation suggests a separate stage from the ‘other’ common motivational forces associated with driving change in practices.

Important to this framework and emerging from the data is ‘the process of decision-

making’. While it was never defined in the emerging framework, it can be inferred that the decision to implement an information system for chronic conditions in these successful approaches, does not happen as a result of a sudden awareness of a chronic condition problem at the practice. That is, it did not happen at the starting (Problem Definition) point of the process as was assumed in the emerging framework. Data collected and the way the interview protocol sequence was developed, began to indicate that decision-making

happened at a particular later stage. Moreover as a result of the amount of ground work put into the analysis and development stages by the champions and the Division IT/IM person before presenting the evidence to the decision makers, the decision makers had before them all the relevant information to make an informed decision. This information included: 1) a complete chronic condition gap analysis (evidence), 2) practice capacity sorted out (Human resources, schedules, roles, etc), financial details and forecasts, risk and liabilities and a variety of implementation models to decide on. There was a clear picture of

driving/motivational forces and potential projected health outcomes.

This section in the study shows the link between practice capacities (already discerned in the previous framework) and the importance of pre-analysing and designing a variety of models before decision making and implementation can occur. These findings suggest that this element deserves a section in its own right within the new and revised framework. The implementation and successful adoption of the systems in turn, produced desired outcomes that went on to introduce other information systems for chronic disease care. This is the practical section of this framework relating to the feedback channel and its valid place in it.

Among the identified influences in the emerging framework, the practice champion and the change agent (IT/IM Officer) were seen as having much greater influence in a number of sections of the framework that were not acknowledged in the emerging framework derived from the literature and the IT/IM Officer’s own experience.

For example, their influential role in the problem definition section leading to awareness of a chronic condition, their role in capacity awareness, analysis and development of models

to provide evidence to allow the making of informed decision and in all aspects of the implementation process. Their contribution appears to be closely related to a kind of partnership, although and according to this preliminary data it was not always so. This finding will also need to be reflected in the revised framework.

The initial section of the framework corroborated the potential motivators driving change in general practices at the time of implementation in these successful practices. The data collected accounted for another emerging, and separate, section in the framework that provided the means for identifying and creating awareness of a chronic disease problem at their own practice. Another section, identified in the study, recognised the presence of a certain amount of capacity awareness, pre-analysis and development in the process leading to the last section where decision-making occurs and system were implemented and

(eventually) evaluated for outcomes.

These findings led the researcher to propose the following graphic representation (Table 42) of the revised chronic diseases information systems framework. This newly proposed framework builds on the original emerging framework, and reflects the observations noted from this first data analysis section.

Figure 42 - The Revised Framework

The Functionality of the Revised Framework

The Factors Driving Change represents the accumulation of knowledge that begins to motivate general practice about a particular chronic disease issue. ‘Knowledge’ for the purpose of this framework is defined as ‘the simple awareness of bits of information’ and

motivation is defined as ‘having the desire and willingness to do something’ (Sutton, 1993). The concept here is that awareness creates motivation. This awareness is

represented by non-practice patient-related information; for example, among the external motivators there are media campaigns (TV, radio, etc), division seminars, flyers, and in this cases, even the IT/IM Division facilitator played a role. Then there are the internal motivators; for example, GPs might have a professional interest in cervical cancer; accreditation obligations to introduce systems; financial advantages; risk management requirements, etc. Lastly, it is assumed, as documented in the literature, the Patient Needs also provides another source of influence on the practice (not examined in this section of study). The point to make here is that these are not fixed variables but are time, value and need specific; that is, some will have more influence than others at a particular place and time. The implementation practitioner, or those trying to introduce change in general practice must learn to ‘read’ these undercurrents to take advantage of these influences. The Chronic Disease Problem Definition segment of the framework is not just the desire to do something (motivation), but something more powerful. If, as explained earlier: knowledge is the simple awareness of bits of information, what is being represented here is something akin to ‘understanding’, that is ‘the awareness of the connectedness of this information’ (Wikipedia, 2007). Wikipedia (2007c) also suggests that ‘it is understanding which allows knowledge to be put to use’; and further goes on to clarify that

‘Understanding represents a higher level than simple knowledge’. This is precisely what problem definition, in the context of what has been found in these cases can be interpreted to be all about. For the practitioner, it means looking into the practice databases and extracting ‘patient-related evidence’ to feedback to the champion/s.

Almost inevitably, implementers will be asked to return to start looking at solutions for the problems that have been defined in the searches.

The Practice Capacity, Analysis and Design is where most of the misconceptions and barriers are overcome and potential solutions under a number of possible designs to suit the practice’s uniqueness are looked into and devised. In most cases a full analysis and design is conducted with the champion and other potential supporters as the data showed. This paves the way for the champion to approach the decision makers with a full account of the chronic disease problem at the practice, and strategies and feasible solutions for them to

decide on. If the decision makers approve, the facilitator or external agent is invited back to start the practical implementation process in tandem with the champions.

The Chronic Disease Information System Implementation section deals with the practical set up of the system according to ‘the design’ that the decision makers have agreed on. For the external agent, it would normally involve a number of visits to train a number of staff in their different roles, to clean up databases and create registers, to setup recall and reminders and learn how to use them to their best potential.

The external agent keeps monitoring the working system over time until all gaps and cracks are ironed out and adoption takes place. Finally, outcome assessment timeframes need to be formalised to measure and feedback success. Success breeds success, which is the feedback channel’s purpose. Even in these practices, even with a lack of formal acknowledgment of success, it has allowed practices to move on to other systems.

Conclusion

This section of the study, while corroborating most of the assumptions drawn from the literature and the observations from the IT/IM Officer, also provided a new interpretation from the revised framework to highlight the peculiarities of successful chronic disease information systems as revealed in this data collection phase.

Results from the data collection gave a glimpse of the importance of chronic disease evidence-based understanding built though practice champions in partnership with Division IT/IM program officers. As well as the purposeful place for the making of informed decisions based on sound analysis (practice capacity, practice population health, financial, risk liability, etc) and the design and choice of potential information system models. Furthermore, it was also noted the encouragement and motivation that successful outcome of information systems will have on the further development of new systems to care for chronic disease patients.

This section of the study shows that the framework now resembles more closely the

journey travelled by these successful practices. However, it must be acknowledged that the picture is not complete. The framework has not been tested in implementations that cater for other chronic conditions like Asthma, Diabetes or Mental Health that are deemed to be more complex for practices to manage. Perhaps in doing so, some other inferences

emerging in this study could be investigated. For example, if the same framework applies to the application of other chronic conditions information systems after the first

implementation? Or if, for example: governance/distribution of power or even ownership plays a mayor role? Moreover, maybe a broader validation is needed with other practice individuals than those studied here (champions) or practices where success was not formally achieved to further validate the finding in this stage.