Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems

ABSTRACT: BACKGROUND: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated largescale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. METHODS: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS). Results/discussion We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations intervention changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. SUMMARY: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.     

Safe abdominoplasty with extensive liposuctioning

In a review of the recent literature, liposuction and tumescent fluid injection are accompanied by hazards of ischemia, flap necrosis, and wound dehiscence at the time of abdominoplasty. The problems that generate complaints from patients and dissatisfaction with tummy tuck surgery are: fullness of flanks and epigastric areas, lack of a posterior lumbar curve, hanging skin over the incision line, and visible scars over the flanks and beyond underwear or swimming suit coverage. The purpose of this article is to introduce modalities to perform liposuctioning of the whole abdomen without confronting the danger of ischemia or flap necrosis. Wide lipoaspiration at the time of abdominoplasty and removing the flanks and epigastric fullness result in a shorter incision line and more natural-looking abdomen. In this article, the authors explain their experience using a new method to omit the complications of classic abdominoplasty surgery in 56 cases performed over a 3-year period (2000-2003).     

Management of the thick-skinned nose: A more effective approach

A bulky nose is a challenging issue to manage, and surgeons have not found the ultimate solution to this problem in the evolution of rhinoplastic surgery. Because of the multiplicity of techniques and controversies published in the literature, it has become confusing for the operating surgeon to find the most appropriate and effective way of solving this frustrating dilemma. The subcutaneous fat is the thickest in the supratip area, and the soft tissue thickness over the tip of the nose varies considerably from patient to patient. The focus of this study was to find a method for reducing the overlying soft tissue of the tip for better re-draping of skin over the nasal skeleton. The hallmark of this technique is to undermine the nasal skin in two layers. We believe that soft tissue trimming in biplane dissection can minimize the thickness of the tip skin in a relatively safe and homogeneous way. With this report we introduce a new method of dissection of nasal soft tissue and of trimming it in different areas of the nose for different purposes. In the authors' opinion, this approach is one of the most effective ways of handling unpliable, thick nasal skin.     

Photosensitizing and radiosensitizing effects of mitoxantrone: combined chemo-, photo-, and radiotherapy of DFW human melanoma cells

This study evaluated the effects of mitoxantrone (MX), an antitumor agent, as a sensitizer to both photodynamic and radiation therapy in DFW human melanoma cells. Cells were incubated with MX at different concentrations for 90 min and then exposed to non-coherent light at different fluence rates and/or X-ray ionizing radiation at different dose rates. Combinatorial effects of this chemo-, photo-, and radiotherapy were also evaluated. MX had no significant effects on viability at moderate doses but had a strong cytotoxic effect on cancer cells when used as a photosensitizer. MX also acted as a potent radiosensitizer. We observed a dose-dependent effect on cell viability in cells exposed to MX in combination with phototherapy and radiotherapy. Strong synergistic effects were observed for combinations of two or more treatment methods, which, in some cases, induced complete cell death. Thus, a combination of ionizing radiation with MX-mediated photodynamic therapy could serve as a new method for cancer therapy with fewer adverse side effects.     

Rituximab induced cytokine release syndrome in an MS patient: A case report

Cytokine release syndrome with rituximab has been reported in certain diseases, however, it is rarely reported in MS patients treated with rituximab. The treating physician should suspect the syndrome when typical signs and symptoms appear.     

Dual-energy CT evaluation of gastrointestinal bleeding

Abdominal Radiology - Gastrointestinal bleeding is a common cause for hospital admissions and is an important cause of morbidity and mortality. Although endoscopy is accepted as the standard...