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.     

Cost-effectiveness evaluation of clobetasol propionate shampoo (CPS) maintenance in patients with moderate scalp psoriasis: a Pan-European analysis

Background Scalp psoriasis is a difficult to treat and usually chronic manifestation of psoriasis. The CalePso study showed that CPS (Clobex^® Shampoo) in maintenance therapy of scalp psoriasis (twice weekly) significantly increases the probability of keeping patient under remission during 6 months, compared with vehicle (40.3% relapses vs. 11.6% relapses, ITT). Objective The objective of the study was to assess the cost‐effectiveness of a maintenance therapy with CPS vs. its vehicle in nine European countries. Methods A 24‐week decision tree model was developed with 4‐weekly time steps. The considered population has moderate scalp psoriasis successfully treated with a daily application of CPS up to 4 weeks. Data were taken from the CalePso study and from national experts’ recommendations for alternative treatment choices, with their probabilities of success taken from literature to develop country‐specific models. Health benefits are measured in disease‐free days (DFD). The economic analysis includes drug and physician costs. A probabilistic sensitivity analysis (PrSA) assesses the uncertainty of the model. Results Depending on the country, the mean total number of DFDs per patient is 21–42% higher with CPS compared with vehicle, and the mean total cost is 11–31% lower. The mean costs per DFD are 30–46% lower with CPS compared with the vehicle. The PrSA showed in 1000 simulations that CPS is more effective vs. vehicle in 100% of the cases and less expensive than its vehicle in 80–99% of the cases. Conclusion This model suggests that CPS is cost‐effective in maintaining the success achieved in moderate scalp psoriasis patients.     

Tripled semitendinosus-cancellous bone anterior cruciate ligament reconstruction with bioscrew fixation.

A prospective evaluation of a tripled semitendinosus-autologous cancellous bone plug ACL reconstruction, secured with bioabsorbable interference screws (Bioscrew; Linvatec, Largo, FL) made of polyL-lactic acid, was undertaken from July 1994 through August 1995. A total of 21 patients with 22 anterior cruciate ligament (ACL) reconstructions were followed-up an average 29 months (range, 20 to 45). The average age was 38 years (range, 24 to 48 years). Tegner and Lysholm scores were 2.1 and 46, respectively, preoperatively and increased postoperatively to 4.4 and 90. KT tests at 24 months follow-up showed an average 20-lb laxity of 1.4 mm, an average 30-lb laxity of 2.1 mm, and an average KT maximum manual side-to-side difference of 2.9 mm. A pivot shift was absent in all but two patients at final follow-up. Full extension was rapidly achieved in all cases and flexion averaged 135 degrees at follow-up. No problems with the poly L-lactic acid interference screws occurred. These data support the effectiveness of Bioscrew fixation of the tripled semitendinosus-cancellous bone graft ACL reconstruction, which achieves both anatomic graft position and anatomic graft fixation.     

Forecasting the need for medical specialists in Spain: application of a system dynamics model

Background  

Spain has gone from a surplus to a shortage of medical doctors in very few years. Medium and long-term planning for health professionals has become a high priority for health authorities.     

Characterization of peach thaumatin‐like proteins and their identification as major peach allergens

Background Peach is the most important fruit related to food allergy in the Mediterranean area. Pru p 3, its lipid transfer protein, has been described as the principal allergen responsible for cross‐reactivities with other foods and pollen and the severity of clinical symptoms. However, the involvement of other allergenic families cannot be ruled out. Thaumatin‐like proteins (TLPs) have been described as food allergen in several fruits, such as apple, cherry, kiwi and banana, and pollen. Objective To identify members of the TLP family in peach fruit and to characterize putative allergens. Methods Through two‐dimensional (2D) electrophoresis of peach extract and immunodetections with a pool of peach‐allergic patients, IgE‐binding spots were identified and the corresponding proteins purified and characterized as allergens by in vitro and in vivo assays. Three isoforms, belonging to the TLP family, were purified by different chromatographic systems and characterized by N‐terminal amino acid sequences, molecular weight determination (MALDI) and enzymatic activity analysis (β‐1,3‐gluconase test and inhibition growth of fungi). In the same way, their IgE‐binding capacity and allergenic activity were tested by ELISA assays, basophil activation tests and skin prick tests (SPT). Results Two peach‐TLPs, Pru p 2.0101 and Pru p 2.0201, were identified as IgE‐binding spots by 2D electrophoresis. Another peach‐TLP, Pru p 2.0301, was cloned and produced as recombinant protein in a yeast system. The three isoforms were purified and characterized as TLPs by immunoblotting with anti‐chestnut TLP antibodies and anti‐plant N‐asparagine complex glycan (anti‐cross‐reactive carbohydrate determinant). All of them showed β‐1,3‐glucanase activity and inhibition of fungal growth. The three TLPs were recognized by around 50% of the sera from 31 patients analysed in ELISA experiments. All three gave a positive response to an SPT and/or in basophil activation experiments. Conclusion Three isoforms, belonging to the TLP family, were identified in peach as principal allergens. Their prevalence, observed in in vitro, ex vivo and in vivo analyses, suggests that they are important allergens and should therefore be included in the routine diagnosis of peach allergy, at least in the Mediterranean area. Cite this as: A. Palacín, L. Tordesillas, P. Gamboa, R. Sanchez‐Monge, J. Cuesta‐Herranz, M. L. Sanz, D. Barber, G. Salcedo and A. Díaz‐Perales, Clinical & Experimental Allergy, 2010 (40) 1422–1430.