The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.
Allison, J., Kiefe, C. I., & Weissman, N. (1999). Can data-driven benchmarks be used to set the goals of Healthy People 2010?American Journal of Public Health, 89(1), 61-65.
2.
Avorn, J., & Soumerai, S. (1983). Improving drug therapy decisions through educational outreach. A randomized controlled trial of academically based “detailing.”New England Journal of Medicine, 308(24), 1457-1463.
3.
Bandura, A. (1977). Self-efficacy: Towards a unifying theory of behavior change. Psychological Review, 84, 191-215.
4.
Berlowitz, D. R., Young, G. J., Hickey, E. C., Saliba, D., Mittman, B. S., Czernowski, E., et al. (2003). Quality improvement in nursing homes. Health Services Research, 38(1), 65-81.
5.
Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., & Thomson, M. A. (1998). Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317(7156), 465-468.
6.
Berwick, D.,& Nolan, T. (1998). Physicians as leaders in improving health care. Annals of Internal Medicine, 128, 289-292.
7.
Borbas, C., Morris, N., McLaughlin, B., Asinger, R., & Gobel, F. (2000). The role of clinician opinion leaders in guideline implementation and quality improvement (review). Chest, 118(2), 24S-32S.
8.
Bradley, E. H., Webster, T. R., Baker, D., Schlesinger, M., Inouye, S. K., Barth, M. C., et al. (2004). Translating research into practice: Speeding the adoption of innovative health care programs[Issue Brief]. New York: Commonwealth Fund.
9.
Buntinx, F., Winkens, R., Grol, R., & Knottnerus, J. A. (1993). Influencing diagnostic and preventive performance in ambulatory care by feedback and reminders: A review. Family Practice, 10, 219-228.
10.
Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P. A. C., et al. (1999). Why don’t clinicians follow practice guidelines? A framework for improvement. Journal of the American Medical Association, 282(15), 1458-1465.
11.
Christensen, S., & Westenholz, A. (2000). Collective decision making: Toward a relational perspective. American Behavioral Scientist, 43(8), 1301-1315.
12.
Cohen, D., McDaniel, R. R., Crabtree, B., Ruhe, M. C., Weyer, S. M., Tallia, A., et al. (2004). A practice change model for quality improvement in primary care practice. Journal of Healthcare Management, 49(3), 155-168.
13.
Counte, M. A.,& Meurer, S. (2001). Issues in the assessment of continuous quality improvement implementation in health care organizations. International Journal for Quality in Health Care, 13(3), 197-207.
14.
Crabtree, B. F., Miller, W. L., Aita, V. A., Flocke, S. A., & Stange, K. C. (1998). Primary care practice organization and preventive services delivery: A qualitative analysis. Journal of Family Practice, 46, 403-409.
15.
Cunningham, R. (2004). Professionalism reconsidered: Physician payment in a small-practice environment. Health Affairs, 23(6), 36-47.
16.
Davis, D., O’Brien, M. A. T., Freemantle, N., Wolf, F., Mazmanian, P., & Taylor-Vaisey, A. (1999). Impact of formal continuing medical education: Doconferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health outcomes?Journal of the American Medical Association, 282(9), 867-874.
17.
de Fine Olivarius, N., Beck-Nielsen, H., Helms Andreasen, A., Horder, M., & Pedersen, P. A. (2001). Randomised controlled trial of structured personal care of type 2 diabetes mellitus. British Medical Journal, 323, 1-9.
18.
Donaldson, M.,& Mohr, J. (2000). Exploring innovation and quality improvement in health care micro-systems: A cross-case analysis. Washington, DC: Institute of Medicine–Committee on Quality of Health Care in America, National Academy Press.
19.
Eisenberg, J. (1986). Doctors’ decisions and the cost of medical care: The reasons for doctors’ product patterns and ways to change them. Ann Arbor, MI: Health Administration Press.
20.
Evans, R. S., Pestotnik, S. L., Classen, D. C., Clemmer, T. P.,& Weaver, L. K. (1998). A computerassisted management program for antibiotics and other antiinfective agents. New England Journal of Medicine, 338(4), 232-238.
21.
Feifer, C., Fifield, J., Ornstein, S., Karson, A. S., Bates, D. W., Jones, K. R., et al. (2004). From research to daily clinical practice: What are the challenges in translation?Joint Commission Journal on Quality and Safety, 30(5), 235-245.
22.
Feifer, C., & Ornstein, S. M. (2004). Strategies for increasing adherence to clinical guidelines and improving patient outcomes in small primary care practices. Joint Commission Journal on Quality and Safety, 30(8), 432-441.
23.
Flottorp, S., Havelsrud, K., & Oxman, A. D. (2003). Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care—Why is it so hard to change practice?Family Practice, 20(3), 333-339.
24.
Gabbay, J., & May, A. L. (2004). Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. British Medical Journal, 329, 1013-1013.
25.
Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care: A systematic review. Journal of the American Medical Association, 289(23), 3145-3151.
26.
Ginexi, E., & Hilton, T. (in press). Bridging the basic/applied science link: Back and forward translation. Evaluation & the Health Professions.
27.
Glaser, B. G. (1998). Doing grounded theory: Issues and discussions. Mill Valley, CA: Sociology Press.
28.
Gordon, P.,& Chin, M. (2004). Achieving a new standard in primary care for low-income populations: Case studies of redesign and change through a learning collaborative. New York: Commonwealth Fund.
29.
Greco, P. J.,& Eisenberg, J. M. (1993). Changing physicians’practices. New England Journal of Medicine, 329(17), 1271-1274.
30.
Greer, A. L. (1988). The state of the art versus the state of the science: The diffusion of newmedical technologies into practice. International Journal of Technological Assessment of Health Care, 4, 5-26.
31.
Griffin, S., & Kinmonth, A. (2000). Systems for routine surveillance for people with diabetes mellitus (TheCochraneDatabase of Systematic Reviews [computer file]). Cochrane Library.
32.
Grol, R., & Grimshaw, J. (1999). Evidence-based implementation of evidence-based medicine. Joint Commission Journal on Quality and Safety, 25(10), 503-513.
33.
Gustafson, D. H., Sainfort, F., Eichler, M., Adams, L., Bisognano, M., & Steudel, H. (2003). Developing and testing a model to predict outcomes of organizational change. Health Services Research, 38(2), 751-756.
34.
Hulscher, M., Laurant, M., Wensing, M., & Grol, R. (1999). Planning, monitoring, and describing interventions. In T. Thorsen & M. Makela (Eds.), Changing professional practice: Theory and practice of clinical guidelines implementation(pp. 133-152). Copenhagen, Denmark: Danish Institute for Health Services Research and Development.
35.
Hunt, D. L., Haynes, R. B., Hanna, S. E.,& Smith, L. K. (1998). Effects of computer-based clinical decision support systems on physician performance and patient outcomes. A systematic review. Journal of the American Medical Association, 280(15), 1339-1346.
36.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine–Committee on Health Care Quality in America, National Academy Press.
37.
Kirby, D. (2000). Logic models: A useful tool for designing, strengthening, and evaluating programs to reduce adolescent pregnancy. Scotts Valley, CA: ETR Associates.
38.
Knowles, M. S. (1970). The modern practice of adult education. Andragogy versus pedagogy. Englewood Cliffs, NJ: Prentice Hall.
39.
Kotler, P. (1984). Social marketing in health behavior. In L. W. Frederiksen, L. J. Solomon,& K. A. Brehony (Eds.), Marketing health behaviors: principles, techniques and applications (pp. 23-39). New York: Plenum.
40.
Kotter, J. (1999, Fall). Winning at change[Online]. Leader to Leader, 10, 27-33. Retrieved January 16, 2002, from http://leadertoleader.org/leaderbooks/L2L/fall98/kotter.html
41.
Lee, W. B.,& Steinberg, E. (1980). Making implementation a success of failure. Journal of Systems Management, 3(4), 19-25.
42.
Logan, J., & Graham, I. D. (1998). Toward a comprehensive interdisciplinary model of health care research use. Science Communication, 20(2), 227-146.
43.
Lomas, J. (1994). Medicine in context: A neglected perspective in medical education. Academic Medicine, 69(10), S95-S101.
44.
McPhee, S. J., Bird, J. A., Jenkins, C. N.,& Fordham, D. (1989). Promoting cancer screening: A randomized, controlled trial of three interventions. Archives of Internal Medicine, 149, 1866-1872.
45.
Miller, L., McDaniel, R., Crabtree, B., & Stange, K. (2001). Practice jazz: Understanding variation in family practices using complexity science. Journal of Family Practice, 50(10), 872-878.
46.
Miller, R. H., Sim, I.,& Newman, J. (2003). Electronic medical records: Lessons fromsmall physician practices. Oakland: California Health Care Foundation.
47.
Miller, R. H., West, C., Brown, T. M., Sim, I., & Ganchoff, C. (2005). The value of electronic health records in solo or small group practices. Health Affairs, 24(5), 1127-1137.
48.
Mittman, B., Tonesk, X., & Jacobson, P. (1992). Implementing clinical practice guidelines: Social influence strategies and provider behavior change. Quality Review Bulletin, 18(12), 413-422.
49.
Moulding, N. T., Silagy, C. A.,& Weller, D. P. (1999). Aframework for effective management of change in clinical practice: Dissemination and implementation of clinical practice guidelines. Quality in Health Care, 8(3), 177-183.
50.
Ornstein, S., Jenkins, R. G., Nietert, P. J., Feifer, C., Roylance, L. F., Nemeth, L., et al. (2004). A multimethod quality improvement intervention to improve preventive cardiovascular care: A cluster randomized trial. Annals of Internal Medicine, 141(7), 523-532.
51.
Ovretveit, J., & Gustafson, D. (2003). Improving the quality of health care: Using research to inform quality programs. British Medical Journal, 326, 759-761.
52.
Oxman, A. D., Thomson, M. A., Davis, D. A.,& Haynes, R. B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153(10), 1423-1431.
53.
Plsek, P. (2001). Redesigning health care with insights from the science of complex adaptive systems. In Institute of Medicine (Ed.), Crossing the quality chasm: A new health system for the 21st century(pp. 322-335). Washington, DC: National Academy Press.
54.
Prochaska, J., & DiClemente, C. (1984). The transtheoretical approach: Crossing traditional boundaries of change. Homewood, IL: Dow Jones/Irwin.
55.
Rogers, E. M. (1962). Diffusion of innovations. New York: Free Press.
56.
Rousseau, N., McColl, E., Newton, J., Grimshaw, J.,& Eccles, M. (2003). Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. British Medical Journal, 326(7384), 314-314.
57.
Senge, P. (1990). The fifth discipline: The art and practice of the learning organization. New York: Currency Doubleday.
58.
Shea, S., DuMouchel, W., & Bahamonde, L. (1996). A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. Journal of the American Medical Informatics Association, 3(6), 399-409.
59.
Shojania, K. G., & Grimshaw, J. M. (2005). Evidence-based quality improvement: The state of the science. Health Affairs, 24(1), 138-150.
60.
Shojania, K. G., McDonald, K. M., Wachter, R. M.,& Owens, D. K. (2004). Closing the quality gap: A critical analysis of quality improvement strategies, Volume 1–Series overview and methodology(Technical Review 9 AHRQ Publication No. 04-0051-1). Rockville, MD: Agency for Healthcare Research and Quality.
61.
Shortell, S., Bennett, C., & Byck, G. (1998). Assessing the impact of continuous quality improvement on clinical practice: What will it take to accelerate progress. Milbank Quarterly, 76(4), 1-37.
62.
Shortell, S. M., O’Brien, J. L., Carman, J. M., Foster, R. W., Hughes, E. F. X., Boerstler, H., et al. (1995). Assessing the impact of continuous quality improvement/total quality management: Concept versus implementation. Health Services Research, 30(2), 377-401.
63.
Solberg, L., Brekke, M., Fazio, C., Fowles, J., Jacobsen, D., Kottke, T., et al. (2000). Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Joint Commission Journal on Quality Improvement, 26, 171-188.
64.
Solomon, N. A.,& Powers, M. (2002). Technical assistance for improving chronic care practices under pay for performance. Oakland: California HealthCare Foundation.
65.
Spencer, E., Swanson, T., Hueston, W. J., & Edberg, D. L. (1999). Tools to improve documentation of smoking status: Continuous quality improvement and electronic medical records. Archives of Family Medicine, 8(1), 18-22.
66.
Stevenson, K., Baker, R., Farooqi, A., Sorrie, R.,& Khunti, K. (2001). Features of primary health care teams associated with successful quality improvement of diabetes care: A qualitative study. Family Practice, 18(1), 21-26.
67.
Stone, E. G., Morton, S. C., Hulscher, M. E., Maglione, M. A., Roth, E. A., Grimshaw, J. M., et al. (2002). Interventions that increase use of adult immunization and cancer screening services: A meta-analysis. Annals of Internal Medicine, 136(9), 641-651.
68.
Sussman, S., Valente, T. W., Rohrbach, L. A., Skara, S., Pentz, M. A. (2006). Translation in the health professions: Converting science into action. Evaluation & the Health Professions, 29(1), pp. 7-32.
69.
Taplin, S., Galvin, M. S., Payne, T., Coole, D., & Wagner, E. (1998). Putting population-based care into practice: Real option or rhetoric. Journal of the American Board of Family Practice, 11(2), 116-126.
70.
Thomson O’Brien, M. A., Oxman, A. D., Davis, D. A., Haynes, R. B., Freemantle, N.,& Harvey, E. L. (2000a). Audit and feedback versus alternative strategies: Effects on professional practice and health care outcomes (The Cochrane Database of Systematic Reviews [computer file]). Cochrane Library. Oxford: Update Software.
71.
Thomson O’Brien, M. A., Oxman, A. D., Davis, D. A., Haynes, R. B., Freemantle, N.,& Harvey, E. L. (2000b). Educational outreach visits: Effects on professional practice and health care outcomes (The Cochrane Database of Systematic Reviews [computer file CD000409]). Cochrane Library. Oxford: Update Software.
72.
Thomson O’Brien, M. A., Oxman, A. D., Haynes, R. B., Davis, D. A., Freemantle, N.,& Harvey, E. L. (2000). Local opinion leaders: Effects on professional practice and health care outcomes (The Cochrane Database of Systematic Reviews [computer fileCD000125]). Cochrane Library. Oxford: Update Software.
73.
Tierney, W. M., Hui, S. L., & McDonald, C. J. (1986). Delayed feedback of physician performance versus immediate reminders to perform preventive care: Effects on physician compliance. Medical Care, 24, 659-666.
74.
Van Bokhoven, M. A., Kok, G.,& van derWeijden, T. (2003). Designing a quality improvement intervention: A systematic approach. Quality and Safety in Health Care, 12, 215-220.
75.
Verstappen, W. H., van derWeijden, T., Sijbrandij, J., Smeele, I., Hermsen, J., Grimshaw, J., et al. (2003). Effect of a practice-based strategy on test ordering performance of primary care physicians: A randomized trial [see comment]. Journal of the American Medical Association, 289(18), 2407-2412.
76.
Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness?Effective Clinical Practice, 1(1), 2-4.
77.
Wagner, E. H., Glasgow, R. E., Davis, C., Bonomi, A. E., Provost, L., McCulloch, D., et al. (2001). Quality improvement in chronic illness care: A collaborative approach. Joint Commission Journal on Quality Improvement, 27(2), 63-80.
78.
Walker, A. E., Grimshaw, J., Johnston, M., Pitts, N., Steen, N., & Eccles, M. (2003). PRIME— Process modelling in Implementation research: Selecting a theoretical basis for interventions to change clinical practice. BMC Health Services Research, 3(1), 22-22.
79.
Walker, E., Wylie-Rosett, J., Shamoon, H., Engel, S., Basch, C., Zybert, P., et al. (1995). Program development to prevent diabetes complications: Assessment of barriers in an urban clinic. Diabetes Care, 18(9), 1291-1293.
80.
Wells, K. B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J., et al. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial. Journal of the American Medical Association, 283(2), 212-220.
81.
Western Electric Company. (1984). Statistical quality control handbook. Indianapolis, IN: AT & T Technologies Inc.
82.
Woolf, S. H. (2000). Changing physician practice behavior: The merits of a diagnostic approach. Journal of Family Practice, 49(2), 126-129.
