Arduous implementation: Does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice

Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, CF14 4YS, UK.
Implementation Science (Impact Factor: 4.12). 01/2009; 3(1):57. DOI: 10.1186/1748-5908-3-57
Source: PubMed


Decision support technologies (DSTs, also known as decision aids) help patients and professionals take part in collaborative decision-making processes. Trials have shown favorable impacts on patient knowledge, satisfaction, decisional conflict and confidence. However, they have not become routinely embedded in health care settings. Few studies have approached this issue using a theoretical framework. We explained problems of implementing DSTs using the Normalization Process Model, a conceptual model that focuses attention on how complex interventions become routinely embedded in practice.
The Normalization Process Model was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment we applied the model and its main concepts to examine: the 'workability' of DSTs in professional-patient interactions; how DSTs affect knowledge relations between their users; how DSTs impact on users' skills and performance; and the impact of DSTs on the allocation of organizational resources.
A conceptual analysis using the Normalization Process Model provided insight on implementation problems for DSTs in routine settings. Current research focuses mainly on the interactional workability of these technologies, but factors related to divisions of labor and health care, and the organizational contexts in which DSTs are used, are poorly described and understood.
The model successfully provided a framework for helping to identify factors that promote and inhibit the implementation of DSTs in healthcare and gave us insights into factors influencing the introduction of new technologies into contexts where negotiations are characterized by asymmetries of power and knowledge. Future research and development on the deployment of DSTs needs to take a more holistic approach and give emphasis to the structural conditions and social norms in which these technologies are enacted.

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    • "However there is a multitude of definitions and measures devoted to patient-centred care [28] [29], which tends to obscure its utility to guide practice. Alternatively, shared decision making (SDM) is an evidence-based approach that built on patientcentred care [30] [31] [32] but which emphasises implementation, as difficulty in adopting new ways of interacting with patients in routine care has been widely reported [33] [34]. Efforts to facilitate implementation are reflected in studies such as Elwyn et al. [35] in which a three-step delivery of SDM: choice, option and decision talk, is recommended. "
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    • "The Patient Protection and Affordable Care Act, signed into the law of the United States in March 2010, contains provisions aimed at encouraging the use of SDM, which represents an important entry point for SDM into public policy [6-8]. Despite these positive developments, the use of SDM remains low due to many barriers blocking its full implementation in clinical practice [9-11]. "
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    ABSTRACT: Background Shared Decision Making (SDM) is increasingly advocated as a model for medical decision making. However, there is still low use of SDM in clinical practice. High impact factor journals might represent an efficient way for its dissemination. We aimed to identify and characterize publication trends of SDM in 15 high impact medical journals. Methods We selected the 15 general and internal medicine journals with the highest impact factor publishing original articles, letters and editorials. We retrieved publications from 1996 to 2011 through the full-text search function on each journal website and abstracted bibliometric data. We included publications of any type containing the phrase “shared decision making” or five other variants in their abstract or full text. These were referred to as SDM publications. A polynomial Poisson regression model with logarithmic link function was used to assess the evolution across the period of the number of SDM publications according to publication characteristics. Results We identified 1285 SDM publications out of 229,179 publications in 15 journals from 1996 to 2011. The absolute number of SDM publications by journal ranged from 2 to 273 over 16 years. SDM publications increased both in absolute and relative numbers per year, from 46 (0.32% relative to all publications from the 15 journals) in 1996 to 165 (1.17%) in 2011. This growth was exponential (P < 0.01). We found fewer research publications (465, 36.2% of all SDM publications) than non-research publications, which included non-systematic reviews, letters, and editorials. The increase of research publications across time was linear. Full-text search retrieved ten times more SDM publications than a similar PubMed search (1285 vs. 119 respectively). Conclusion This review in full-text showed that SDM publications increased exponentially in major medical journals from 1996 to 2011. This growth might reflect an increased dissemination of the SDM concept to the medical community.
    Full-text · Article · Aug 2014 · BMC Medical Informatics and Decision Making
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    • "Methods to improve health literacy and shared decision making [31] show some effectiveness, but are often difficult to implement in routine practice [39], where too much is often asked of patients [40]. Interventions designed to improve patient– provider communication [10] [23] are seen as essential to good patient-centered care, yet have not been routinely implemented into clinical care [41] [42]. 3.3. "
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    ABSTRACT: Objective Examine existing reviews of patient engagement methods to propose a model where the focus is on engaging patients in clinical workflows, and to assess the feasibility of advocated patient engagement methods. Methods A literature search of reviews of patient engagement methods was conducted. Included reviews were peer-reviewed, written in English, and focused on methods that targeted patients or patient-provider dyads. Methods were categorized to propose a conceptual model. The feasibility of methods was assessed using an adapted rating system. Results We observed that we could categorize patient engagement methods based on information provision, patient activation, and patient-provider collaboration. Methods could be divided by high and low feasibility, predicated on the extent of extra work required by the patient or clinical system. Methods that have good fit with existing workflows and that require proportional amounts of work by patients are likely to be the most feasible. Conclusions Implementation of patient engagement methods is likely to depend on finding a “sweet-spot” where demands required by patients generate improved knowledge and motivate active participation. Practice implications Attention should be given to those interventions and methods that advocate feasibility with patients, providers, and organizational workflows.
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