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Panelists of Knowledge Dissemination & Outreach Education: Implementation Strategies and GHDonline staff

Knowledge Dissemination & Outreach Education: Implementation Strategies

Posted: 01 Jun, 2015   Recommendations: 31   Replies: 75

A well-established lag time exists between the publication of new clinical evidence, and the full integration of these findings into health care delivery systems. Research in the United States suggests that it may take, on average, 17 years for evidence to reach clinical practice.

Significant policy and research efforts have focused on strategies for reducing this gap, to identify new incentives and approaches that can better facilitate the dissemination and translation of evidence-based recommendations into practice.

To better understand some of these knowledge dissemination and outreach education strategies being implemented in the United States and around the world, GHDonline has invited a group of expert panelists to share and discuss their work, during the week of June 8 – 12.

We’re pleased to welcome our panelists for this discussion:

     • Michael Fischer, MD, MS, Director of the National Resource Center for Academic Detailing (NaRCAD.org), and Associate Professor of Medicine at Harvard Medical School
     
     • Carol Havens, MD, Director of Physician Education and Development, Kaiser Permanente

     • Amanda Kennedy, PharmD, BCPS, Director, Vermont Academic Detailing Program, and Associate Professor of Medicine, University of Vermont

     • Lyndee Knox, PhD, Executive Director, LA Net Collaboratory

     • Lynn Weekes, PhD, CEO of NPS MedicineWise

Our panelists will offer insight into the following questions:

1. How can outreach education help close the “know-do” gap?
2. Where do you begin identifying the needs in a program, or the groups you work with?
3. What tools, techniques, or communication strategies are most effective in helping health care professionals adopt best practices?
4. What factors are critical to the success of outreach education programs? What are some of the challenges you and your colleagues have encountered with implementation?
5. What does success look like? How do you measure the efficacy and impact of knowledge dissemination and outreach education programs?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, we’ve created a short (4 question) survey. Your responses are greatly appreciated—please take the survey before the discussion begins: https://www.surveymonkey.com/s/XS6WFD7

We look forward to a rich discussion next week—please join the conversation and share your questions or comments for our panelists!

Replies

 

Raghavendra Guru Srinivasan Replied at 11:29 AM, 1 Jun 2015

Dear Sir,
I have a health financing & governance innovation and have attached Global framework for health related food taxes (3 pages).   The work was appreciated by Research Group for G20, WCRF, professors of Harvard university, st. Andrews and IIT Madras. I am looking for a best option to launch this innovation.
How this is innovative 
- The work brings out the comprehensive framework of overeating and the business behaviour of tickling food consumption.  Making a list of causes for overeating could be primary before sorting out the problem.
- Effects of food design/formulation is analysed for excessive consumption and tickle tax is introduced in the paper.  

- I have provided an option of reducing consumption for health policy.  Current policy options involve spending the food tax collections in Fruit & vegetable subsidy, child fitness tax credit, public transit tax credit, Sporting equipment tax credit, subsidized physical activity program, Income transfer healthy food, Income transfer physical activity etc.
- Please note that governments around the world have proposed to tax various food products to stop obesity and diabetes and they include soda tax, candy tax, snack tax, ice cream tax, sugar tax, high salt and high sugar tax, junk food tax, pastry tax, etc.  There were ban on large soda cups in New York.  Even after taxing food products there is still discussion on food supplied in large quantities and promotions to children in the form of gifts and toys. I have simplified them all into Fat and tickle tax which would be a sustainable health financing model.

Please could you help me in bringing out the innovation

Thank you very much indeed.
Truly yours,Guru

Luis Azpurua Replied at 12:06 PM, 1 Jun 2015

Dear Marie,

Thank you very much for the invitation.

For us the major challenge is how to effectively reach the targets groups. We have access to the knowledge but due to the rushing of the nursing / medical activities, misaligned incentives and very basic IT it is very complicated to reach the people and to share the information and its feedback.

I'm looking forward to learn a lot from the discussion.

arnab paul Replied at 4:29 AM, 2 Jun 2015

Dear Marie, Thanks for the invite. There is so much to do in the space, I am really looking forward to this discussion.
Regards
Arnab

nandita chattopadhyay Replied at 11:30 AM, 2 Jun 2015

Dear Marie,.

Thanks so much for the invite.
I work developmental challenges in children, its early identification and
management. A lot of updated knowledge and skill need
skills to be disseminated among professionals, care givers and parents. I
have been conducting training and awareness programs at various levels. I
would like to acquire more information for better dissemination methods.
Looking forward to a stimulating discussion.

Jessica Ludvigsen Replied at 11:43 AM, 2 Jun 2015

Hi everyone,

In preparation for next week's discussion, I wanted to share some resources that might be of interest. Please feel free to share additional resources on this important topic, as well as any questions you'd like to see our panelists address next week.

Looking forward to a great discussion!

Jess

Attached resources:

achint jaiswal Replied at 1:13 AM, 3 Jun 2015

Thanks Jessica for sharing resources.I was in search of this type of
resouces.

Thomas Bauer Replied at 9:17 AM, 3 Jun 2015

I am looking forward to this discussion. Since healthcare is evidence based, frequently the spread of an idea or concept is slowed to assure the research transfers to the unique settings in which healthcare is provided. This creates a culture that assures a safer health care environment but also slows implemenatation of promising ideas It will be interesting to discuss at what point is an idea ready for implemenation...

Jessica Ludvigsen Replied at 9:53 AM, 5 Jun 2015

A reminder that our very short Expert Panel survey is open until Monday morning - your responses to these 4 questions will help us evaluate the impact of these types of discussions here at GHDonline and provide us with incredibly helpful feedback.

Please take a moment to fill out the survey if you haven't already: https://www.surveymonkey.com/s/XS6WFD7

Aamer Ikram Replied at 10:12 AM, 7 Jun 2015

Waiting for the discussion

Lynn Weekes Replied at 7:53 PM, 7 Jun 2015

Academic detailing is a well tested and resource intensive activity so it's important to target it well. After some 17 years of running a national program in Australia we are confident it can help close the knowledge practice gap. It is particularly effective in helping the practitioner reflect on his or her practice, patients and workflow in light of the evidence. Sometimes data will lend greater objectivity to this reflection (in our case that means prescribing data or referrals for for diagnostic tests). Most important is the relationship that the detailed establishes that is trusting, non-judgemental and encouraging of reciprocity.

Michael Fischer Replied at 8:01 AM, 8 Jun 2015

Delighted to be a part of this panel. I would like to kick of the discussion with a response to the first question: How can outreach education close the "know-do" gap? This response is meant to provide a general overview of how we approach academic detailing and related interventions, look forward to engaging with the community on specific questions and challenges.

Outreach education, which includes academic detailing, helps to close the gap between what’s actually happening in a given practice setting and what, optimally, should happen based on the best evidence. To best understand how clinical outreach education can close the “know-do” gap, we must first understand why that gap exists.

The “know-do” gap persists in part due to the manner in which knowledge is published and presented. Front-line clinicians struggle to keep up with a steadily increasing volume of information. Each week, dozens of medical journals publish hundreds of new articles. In addition, guidelines may be released from multiple organizations, often with differences in their recommendations. Clinicians who attempt keep up with this information face a “signal-to-noise” problem when attempting to identify which research results or guidelines should be changing their practice decisions.

Along with the sheer volume of information, another cause of the “know-do” gap is the language used when presenting research findings. Research studies present their primary findings in relatively technical statistical language. This format allows other researchers to evaluate carefully the methods by which a study was conducted, and identify issues or even reproduce the research when needed. For clinicians, however, this format isn’t readily usable. Clinicians face decisions between specific testing or treatment options, often for patients with multiple comorbid conditions. Research studies may not include these kinds of patients, and study results are not presented in a synthesized manner to be used as true decision aids.

Clinical outreach education gives clinicians what they need to close the “know-do” gap: practical information, drawn from the best research, but presented in a manner that recognizes the decisions that must be made in real practice and provides specific action-oriented recommendations. To truly change behavior, well-executed educational interventions must do more than present extensive lists of facts. Effective educational interventions, such as academic detailing, are a service to clinicians, supporting them in examining evidence in order to take the right action when faced with a decision.

Bevin Shagoury Replied at 9:51 AM, 8 Jun 2015

Hi everyone,

As a support to Dr. Fischer's previous response about closing the "know-do" gap, here are some resources that might help to further illustrate some of what that looks like with regard to academic detailing (see below.)

Attached resources:

Madhuri Gandikota Replied at 10:07 AM, 8 Jun 2015

Dear Marie,
Thanks for the invite. Understanding the translation mechanisms to take
years of research and evidence to the bedside is a very important step. I
am looking forward to this rich discussion.

Amanda Kennedy Replied at 10:18 AM, 8 Jun 2015

Hello everyone. I am thrilled to see both new and familiar names in this forum. I would like to echo an important theme shared in the comments that Lynn and Mike have already made related to using academic detailing to close the “know-do” gap.

Academic detailing is a service. This is very important. If your goal is not to provide a service, but rather implement a policy or formulary change, institutional mandate, law, etc., you may be better served by a different intervention.

Academic detailing is about understanding the needs of the customer, who in many cases is a healthcare professional. In practice, I find that most of the time the healthcare professionals I serve are aware of the latest guidelines, facts, and big trials. The reasons those healthcare professionals aren’t implementing changes are far more complex than a knowledge deficit. Barriers to closing the “know-do” gap that I see include lack of time to use an evidence-based tool, not having the correct tools or resources at the point of care, a belief that our patients are different from those studied in large trials, and no access (either due to geography or cost) to appropriate personnel or resources supported by evidence.

By establishing and maintaining the type of trusting relationship that Lynn described, a well-prepared academic detailer can help get to the root of closing the gap with one healthcare professional at a time.

Terryn Naumann Replied at 1:29 PM, 8 Jun 2015

Amanda's comments about NOT using academic detailing as a tool for implementing government policy comes as a welcome reminder. We have a successful academic detailing service which has always focussed on providing clinicicans with evidence based drug information to support their clinical decision making. Recently, we were asked if we could provide 'education on a new policy'. I have been attempting to explain that academic detailing is not the best tool for implementing a policy, however the service's value to health care professionals is seen as a reason why it should be the one to provide the education. I welcome any words that will help me to explan why academic detailing should not be used to provide education on policy.

Lyndee Knox Replied at 1:32 PM, 8 Jun 2015

Hi everyone. I'm excited to be participating on this learning community. I'll follow Michael's lead on the know -do gap. At LA Net (my organization) we use practice facilitators (PF) to help practices close the "know-do" gap. Our PFs are people who are trained in quality improvement methods, change management, Health IT optimization, use of data in performance and pop management, and deep expertise on the specific content of the Know-Do gap we are trying to close. Because it is almost impossible for anyone to possess all these skills, we use PF teams in our intervention -led usually by the PF with expertise in QI. This lead PF is the primary point of contact with the practice and brings in the other team members as needed to support their work with the practice. One of our first lessons learned in working with practices to close the know-do gap is that relationships matter. For outreach education to work it has to be both "high touch" and "high tech". So - our first step in working with any practice is to build relationships. Our PFs do this by setting up a "standing" visit time - so people start to expect them and look forward to their visit. When they start with the practice, they spend several visits just getting to know the people working there, observing their processes, asking questions, listening. We say we know we've been successful in creating the needed trust when the PF is given the combo to the back door. Funders often want us to skip this step because it costs money -but we have found this is almost always a mistake to do so.

Lynn Weekes Replied at 5:37 PM, 8 Jun 2015

Thank you Amanda for your very clear message about academic detailing being service. While knowledge gaps exist and we can measure knowledge improvement often it's the old habits that all of us need to change and this is about practice. Helping clinicians find new ways to practice that is relevant to them and their patients is critical and that may help you think about how the 'knowledge' is presented. I favour behaviour based messages that link as to the clinicians workflow. Some years ago I heard Jonathan Lomas say, use the evidence, critically appraise it and then communicate it as anecdote because clinicians treat one patient at a time.

Lynn Weekes Replied at 6:16 PM, 8 Jun 2015

I am interested in Thomas' question about when an idea is ready for implementation. Certainly some diffusion takes a long time in healthcare but not all. We have all seen the new blockbuster drug that gains very rapid and widespread uptake. One of the advantages of educational outreach is that it allows more nuanced conversations that can place a new way of providing care in context - its place in the spectrum of existing therapies. Academic detailing in particular is well suited to exploring controversial subjects where there is divided opinion about the value of a therapy. It is also very helpful to clinicians when there is high uncertainty in the evidence base. I think one of the reasons for this is that the conversation that forms the basis of the detailing is all about exploring harms and benefits in context and making decisions with less than perfect data. The real world emphasis is powerful.

carol havens Replied at 7:58 PM, 8 Jun 2015

sorry to be late to the discussion! At Kaiser Permanente in Northern California, we have used academic detailing for decades (literally!) to facilitate practice change. There are a variety of reasons for the "know-do" gap. First, assuming the clinician knows the evidence/recommendations, they may not remember them in the crush of everything else, they may not fully believe them, they may not have the tools to implement the recommendations, or there may be patient mediated factors. I am sure we could list even more, but these are the general ones we see most. Academic detailing is a way to both assess and address barriers to change. Yes, its a service, and all clinicians want to provide great care so helping them do so is a service. And I agree with Lynn that those times of uncertainty are a great time for this intervention. But we still come to it with a recommendation, even with the uncertainty, and we need to be able to frame our discussion in the context of risk/benefit to the patient as well as the larger community.

carol havens Replied at 8:03 PM, 8 Jun 2015

and I absolutely agree that relationships matter. In our training we try to reinforce that our focus is not on a single interaction, but rather recurrent ones. Investing up front to establish that trust and mutual goals is so important to long term success. And using stories to make it memorable is also important. I once heard that we are swayed by evidence, but we remember stories-which also helps close the "know-do" gap.

Sandeep Saluja Replied at 9:38 PM, 8 Jun 2015

I agree with Lynn.There is clear need for clinical fora which are not biased or funded by industry and are prepared to critically analyse new therapeutic or diagnostic developments.

Lydia Green Replied at 11:42 PM, 8 Jun 2015

Lynn made an important point: "We have all seen the new blockbuster drug that gains very rapid and widespread uptake." It helps to understand that this doesn’t happen by accident. One thing I have learned in my career in pharmaceutical advertising is the power of a good strategy, well executed.

When it comes to prescription medicines, there is the collective evidence point of view and there is the pharmaceutical, biotech and medical device industry point of view. Many questionable practices in American healthcare - from using erythropoietin in pre-dialysis patients, prescribing of second-generation antipsychotics to children and seniors, and recommending intensive control of blood sugar in all people with Type 2 diabetes - are the outgrowth of well organized, well orchestrated marketing campaigns designed to increase drug sales.

One of the fantastic things about this forum is for people with different experience and perspectives to unite in trying to accelerate adoption of best practices. It really can be done - to achieve that, it helps to look at the successes of the pharmaceutical industry in impacting what providers do and what consumers demand. I firmly believe that it is possible to “re-engineer” their strategies/tactics to promote evidence-based medicine.

When the voice of medical experts is as loud as industry’s, we will see the reign of evidence over marketing in American healthcare. When that happens, we will have a system where each person gets the best possible treatment for their particular condition system, a system where patients — not profits— rules how drugs, devices and diagnostic tests are utilized.

Lyndee Knox Replied at 12:30 AM, 9 Jun 2015

Carol's mention of the power of stories is an important one for us in the outreach education. Once a new treatment or new health care process has a sufficient evidence base behind it- and clinicians have been trained on the content, the next question is how do you help them actually implement what they have learned into practice and institutionalize it. This is where Practice Facilitators come in with expertise in "process" change. Otherwise the clinicians often come back from the trainings jazzed but then in a week or two, things slide back to normal. Maybe they have trouble remembering the changes, or find financial barriers, or patients don't accept it, or it takes too much time... etc. One of the most powerful methods we've found for helping practices implement what they've learned clinically -is by finding "exemplars" in other practices who have figured out how to do whatever the particular task is well. Some call this looking for "positive deviance." Another term is "best practices research" (see article by Jim Mold). Our PFs are trained in identifying "exemplars," documenting their process, and then spreading these approaches to other practices and to other PFs. In other words, the PFs "spread the story" of exemplar practices to others and help them adopt the exemplar processes. These stories usually focus on what seems to be the very mundane - for example, how to get lab results back to patients timely - but that are also things that can make an enormous difference to patients.

Madhuri Gandikota Replied at 2:33 AM, 9 Jun 2015

I am also dwelling on the new reality of the world.
With the advent of App Development, there are so many software tools
(and now the Internet of Things (ioT) devices) being actively developed by the growing number of professionals from all walks of life.
In some of these cases, consumer seems to be king with a wide adoption. While for some advertisement is.

How can one play “catch-up” with these technologies in health care?

How does this landscape change (if any) the respected academic detailing or Practice Facilitators?

Lynn Weekes Replied at 3:14 AM, 9 Jun 2015

Hi Madhuri, the brave new worlds of social media and apps are definitely important although I'm old fashioned enough to still believe in the power of face-to-face relationships. We do need to learn how to harness the relationships that can be developed through social media and apply it to our work. In my program e are only at the stage of remote/virtual detailing to reduce (but not entirely replace) face to face visits in remote parts of the country. Would love to hear of other experiences.

Didier Demassosso Replied at 4:32 AM, 9 Jun 2015

Dear All,

I find this discussion of extreme relevance especially that there is
growing concern in most developing countries (e.g Cameroon) to
consider evidence -based practices and treatment especially with
popular somatic diseases (especially malaria and HIV/AIDS). I
personnallly experienced the prescription of outdated malarial drugs
in a health center. It would be indeed terrible that the lag time of
17 years identified in the US between evidence and pratice persists. I
believe there is reason to think that this lag time (17 years) could
be multiplied several times in the African-Cameroonian context , still
plagued, it is worth saying, by inertia in the developement of a
robust research culture and evidence-based practice. Critical to the
widening of this gap are the aspects of knowlegde sharing and
knowlegde management which is to my view point totally underlooked in
the training of health professionals. I still believe that enabling
health professionals to be exposed to constant healthcare scientific
literature could in the short, meduim and long run be very
significant in reducing the gap. Access to quality health information
via all sorts of possible means (mobile technology is a wonderful
opportunity, mhealth applications and mlearning could serve the
purposes) is to my view point a necessary target for governments of
the south and a democratization of this information by the North a
real need as well. En passant , The open access movement is the
actual effort of this democratization. I have personnally found it
difficult to access healthinformation in some data bases . The fee to
pay to access such information at times worth the minimum wage salary
for a month in my context.

Since globalisation entails interconnectedness, the idea of global
health ought to emphasis on helping/suppporting developing countries
develop robust health systems. It would be catastrophic to my view
point that knowlegde management in the health sector in developing
countries be taken for granted. We have learned a lot from the recent
Ebola outbreaks, it is a lesson for the future of global, regional
and country health developement.

Sven Jungmann Replied at 5:28 AM, 9 Jun 2015

Dear colleagues,

I see the emergence of a highly interesting discussion happening here which reminds me a lot of Roger's work on "The Diffusion of Innovations". I think you might quite enjoy reading it and drew a lot of precious insights from it for a recent pubication in which we explored how end-users (e.g. doctors and patients) can be engaged more in the process of eHealth innovation. From my experience with this research, I can fully agree with Lynn (and Atul Gawande) that people talking to people seems to be a key driver in adoption of new behaviour. However mass media has a powerful role in dissemination knowledge. So both are important in their own merit I'd say. However, my expertise focuses mainly on Europe and I'd be interested in hearing what Non-European people think about how our heuristics apply (or don't) to their countries. Lynn and Madhuri, for example, I could see you have some really interesting feedback on this (I attached a link to my post)? Also, will the panel discussion be recorded for later view or will we have access to a synopsis? It seems highly relevant to my work! Thanks for this excellent initiative!

Attached resource:

Madhuri Gandikota Replied at 6:52 AM, 9 Jun 2015

In all honesty, I was looking for more examples to learn about the value of one-to-one relationships . Being in the so called, APP development world myself (not the words) and in a digitally skewed world in “Silicone valley “ I am looking for evidence to tell my partners (non-health) the relevance of pristine relationships. So with my question, I was hoping to gather evidence on these methods to apply .

For Sven question, I am also looking for the parallel information. However, what I know is : For patients involvement , I know about the “Patients Centered Research Institute” .
What I recently learned is the “ HHS Interoperability roadmap”. Empowering Individuals is one of its guiding principles. What I am looking for the connection of these two, either at the policy level.
( i.e. Empowered Patients in Health IT) or any information from the the big-IT players

Attached resources:

Madhuri Gandikota Replied at 7:17 AM, 9 Jun 2015

Sven,
I donot know if you find these useful.

1) US Centers for Medicare and Medicaid Services (CMS) announced on June 1st, 2015, the release of a large dataset of 2013 to be available outside the research community.
2) Open data Initiatives: To release datasets into public domain.

Attached resources:

Michael Fischer Replied at 7:57 AM, 9 Jun 2015

An interesting discussion here about the roles of personal interactions and of mobile health apps and other technology solutions. I would suggest trying to move away from thinking of these approaches in an "either/or" mode and to instead think about how to combine the approaches in a manner that takes advantage of their relative strengths. When dealing with a significant behavior change by a clinician, such as major new developments in the evidence or redesign of processes in the office, then a one-on-one session allows for a dynamic conversation in which the clinician can state openly their challenges and barriers for making change and an academic detailer or facilitator can form a rapport and help a clinician make evidence-based changes. But there are likely many opportunities for follow-up with additional new evidence, or augmentation of previously discussed messages, that could be delivered rapidly and efficiently by electronic means. A model in which initial relationships are developed in the traditional one-on-one setting and then a mix of both personal and technology-assisted interaction is used for follow-up seems very promising and would be an important area for pilot studies and demonstration projects.

Thomas Bauer Replied at 10:18 AM, 9 Jun 2015

Friends, what a great conversation.. my comments come from the lens of a health care professional and the lessons learned inn losing 189 pounds ... . Lynn's comments about multiple comments from providers and the importance of on-going relationship with my PCP were essential to my journey.... I had heard many times to the point of cognitive dissonance that I needed to lose weight. It was not until my PCP placed it into meaningful context (based on my relationship with him) that I moved from informed to engaged. Based on our relationship, he created a powerful message to me that resulted in moving from knowing to doing or as I refer to from informed to engaged. In fact, he acknowledged that I my blood studies were perfect... He then informed me that my happiness was at risk if I continued my current trajectory due to the increased risk of chronic conditions.... My PCP made this issue a threat to my happiness and forever changed my life....

I believe the lessons I learned as a health literacy and patient engagement during this journey and as part of a support group of over 1500 that the reason people who are morbidly obese lose weight at not always medical....rather lifestyle is a significant (if not dominant) motivator . When I asked those in my support group what they lost weight the answers were surprising and included bending over without gasping for breath when tying shoes, buying clothes off of the rack, not buying 2 seats on a plane, keeping up with their child or grandchild... For some it was medical, but for the majority the decision to lose weight was the negative impact on their ability to enjoy the simple things in life.

Thomas Bauer Replied at 10:30 AM, 9 Jun 2015

I also agree with comments about the importance of support groups. Programs such as Alcoholics Anonymous have proven the value of creating shame free and judgement free relationships in changing and sustaining behavior change.
Leveraging this knowledge in healthcare systems is challenging due to liability and misinformation concerns. We have learned the most functional support groups thrive without the presence of health care professionals monitoring the conversation. (judgement and shame free relationships) However, the presence of health care professionals in the group also increase the validity information shared in a quieter conversation. While some will argue that most support groups self-correct… others will argue this is a dangerous and possibly incorrect assumption. Opportunity exists in finding the sweet spot of creating a judgement and shame free zone while assuring accuracy of information shared.

Marie Connelly Replied at 11:20 AM, 9 Jun 2015

Many thanks to all our panelists and community members for sharing such insightful questions and comments in our Expert Panel so far! As there have been a few questions about the timing of this event, I wanted to clarify that this Expert Panel is a virtual, asynchronous discussion here on GHDonline. There's no specific session to log into or video to watch, so we invite you to share your questions and comments in this discussion as your schedule allows.

We're looking forward to a rich discussion through the rest of the week, but if you have questions about participating in the Expert Panel, please don't hesitate to contact us directly: http://www.ghdonline.org/contact/

Marie Connelly
Manager of Community Strategy, GHDonline

carol havens Replied at 11:26 AM, 9 Jun 2015

I agree with Michael that this is not an either/or. We know multiple interventions are necessary for change to occur, and we should use all of them at our disposal. Some forms are great for disseminating knowledge, some are better at closing the know-do gap, but all are helpful in reducing that 17 year lag. And Lyndees point about the use of exemplars is terrific. It also fits with diffusion theory-if you get the right people promoting your "product", it makes a difference. The marketers certainly know this. But when it comes to clinicians changing practice, often the "local" experts are even more powerful. They are the ones with whom we share patients, practices, communities. If in our academic detailing conversations (or any other), we find that a clinician does not adopt new recommendations because they don't know that their colleagues support it, having that "exemplar" to both endorse the change and show how it can be done can be the tipping point.

carol havens Replied at 11:35 AM, 9 Jun 2015

academic detailing is a pretty resource intensive method to reach physicians. We have many formats at our disposal, including large group didactic, small group case based, technology based with web and e-mail, etc. We typically use academic detailing after many of these others have been deployed to assure that everyone at least has the knowledge of the evidence and the recommendations. We are also blessed with the data about a clinicians actual practice, which is another powerful motivator for change. If we see the change is still not being adopted, its an indication we need to find out what other barriers need to be addressed and we use academic detailing as way to do that (both to assess the barriers and to help address them). Because of the trusted relationship already established, its "judgement free"-as Thomas points out. I have no evidence that this is the right approach, but it seems to work for us.

Emmanuel Ngabire Replied at 11:42 AM, 9 Jun 2015

This is great! Unfortunately the accessibility to Practice-Based
Research—“Blue Highways” on the NIH Roadmap is not free! How can we access
that roadmap?

With many thanks,

Emmanuel

Michael Fischer Replied at 11:48 AM, 9 Jun 2015

Thanks to all for the replies and interesting comments. At the top of the page Marie had posted a list of 5 questions to explore over the course of the week, and this seems like a good time to share some thoughts on the second question: Where do you begin identifying the needs in a program, or the groups you work with?

Academic detailing and other forms of outreach education work to close the gap between what’s actually happening in a given practice setting and what, optimally, should happen based on the evidence. This concept is the foundation to identifying and assessing a program’s needs, as well as the needs of individual clinicians.

For any program that is planning a successful outreach education intervention, the first step in effectively assessing needs is to identify a priority clinical area. A priority area, generally, can be a condition or group of conditions that are highly prevalent and/or cause substantial morbidity in the target patient population.

The next step is to evaluate current patterns of care and/or outcomes in the target population and compare those to the ideal outcomes. This stage is critical to identify the potential effectiveness of the proposed intervention. For example, if a condition turns out not to be highly prevalent in a given setting, or if patterns of care are already meeting targets, then resources for that intervention may not be needed, and it may be more effective to focus on a different topic or intervention

However, if a gap in care is accurately identified, one needs to determine the causes of the gap, and then to design messages and interventions to provide clinicians with the evidence and tools they need to close the gap. Examples of these tools might be a clear management algorithm that clinicians can use when working with patients, a conversation guide to use with patients to promote a particular screening test or behavioral intervention, or other similarly practical approaches to improve care.

Michael Fischer Replied at 11:50 AM, 9 Jun 2015

And picking up on one other element of the second question of the week, assessing needs should not just happen at the programmatic level. During an individual 1:1 visit between an outreach educator and a front-line clinician, needs assessment forms the core of the academic detailing approach. As a form of social marketing, academic detailing relies on a meaningful dialogue between the educator and the clinician. Academic detailers ask open-ended questions to encourage clinicians to reflect on their current practices and challenges that they face. The academic detailer will then tailor his or her outreach to meet the clinican’s needs. This is done by focusing on the specific messages that will allow clinicians to commit to changing their behaviors in ways that support the intervention, for example agreeing that they will use a specific screening tool or treatment algorithm the next time they see a patient for whom they are relevant.

Amanda Kennedy Replied at 1:27 PM, 9 Jun 2015

To respond to a few more comments from the first discussion (and then I promise to post about the second question!)

1. I have seen great examples of blending technology with academic detailing. For example, in the United States Department of Veterans Affairs academic detailing program, they have combined electronic “dashboards” that support their conversation with a prescriber. The dashboard has the ability to show prescribers how their patients are doing in meeting various evidence-based targets. If used supportively rather than punitively, this type of technology can be incredibly motivating and powerful for making behavior changes. However, one should be mindful when it comes to technology in ensuring that the technology supports, but doesn’t replace, the social interaction between the academic detailer and person being detailed.

2. To follow-up on one of Carol’s comments, “Academic detailing is a way to both assess and address barriers to change. Yes, its a service, and all clinicians want to provide great care so helping them do so is a service. And I agree with Lynn that those times of uncertainty are a great time for this intervention. But we still come to it with a recommendation, even with the uncertainty, and we need to be able to frame our discussion in the context of risk/benefit to the patient as well as the larger community.” There is a very important point being made here about a service vs. recommendation. I strongly believe academic detailing encompasses both. The service wouldn’t be worth paying for if it didn’t result in anticipated behavior changes. Therefore every academic detailing visit comes with evidence-based recommendations that are stated as behavior changes. “Use the PHQ-9 for screening for depression with your primary care patients.” The service the academic detailer provides includes the evidence behind this recommendation, the evaluation of needs and barriers to implementing this recommendation, and the tools and resources to facilitate implementing the recommendation.

Amanda Kennedy Replied at 1:45 PM, 9 Jun 2015

Thanks Mike for focusing us on our next question. I can share our approach at the Vermont Academic Detailing Program. Identifying program needs is broad, so I am sharing our approach to topic or module selection, which for our small program amounts to one new topic each year (plus maintaining 4 previous topics).

Most importantly, we rely on what our primary care prescribers (i.e. our customers) tell us they need. We ask at the end of every academic detailing visit what their current challenges are in practice, where they are confused by the evidence, and what they want help with.

We have a stakeholder group, formalized as Academic Detailing Program Advisors. This is an advisory group, not a decision making group. They represent local or state government, insurance companies, professional organizations, community partners, academia, etc. It is a broad group. Our Program Advisors meet annually. Each year at our meeting, I present the list of needs identified by the primary care prescribers and ask the Program Advisors to provide to provide their opinions about what they feel the needs are in our Vermont primary care community within this context. It is important that they add to, but do not replace, what the primary care providers have told us. This way, we ensure our program will continue to be a service.

Our team, consisting of 3 pharmacists and 3 primary care physicians, regularly meet to discuss what guidelines are being released, what we see in the literature related to primary care, and what topics or needs we think are helpful for our audience in terms of closing gaps between actual and ideal practice. We discuss our assessment of our annual Program Advisor meeting within this context and ultimately make a decision about our next topic.

Lyndee Knox Replied at 4:41 PM, 9 Jun 2015

This is a response to Madhuri's question about IT and apps and how they impact practice facilitation. In our work in the Los Angeles safety net there are several things I can share. First is the issue of Health IT in the practices. Almost all of the practices we work with now use some type of electronic health record. This has had a major impact on our work as PFs. There are about 20 different EHRs in use in the LA area that we have to deal with. And our PFs desperately need expertise in these systems. Much of the "workflow" of our practices now consist of "clicks" on an EHR. Our PFs need to know how to "map" these and work with IT/vendors/support to revise them as needed to improve flow. Our PFs learn to create "click" books for clinicians that show them the pathways through their system -these are visual guides -e.g. click here and then here and then here. This has been very valuable to our practices. Our PFs also need to know how to work with IT and support to correct "mapping errors" - these can wreck havoc in a practice if HbA1cs for instance are being mapped to two different places depending on where the info is being entered. Panel management reports then are incomplete as are QI measures. Finally they need to know how to optimize systems -for example helping practices decide on which alerts and clinical decision supports to implement- clinicians and staff will "tune out" if there are too many, or they don't trust them. All of this is central to improving care and going from "know to do" in our practices in LA. BUT here's the rub. Vendors are often not willing to part with this info- they see it as a revenue stream. So our PFs have a very hard time acquiring this knowledge. The way we solve this is to have them sit in on vendor sessions with practices. and to when possible hire former employees of the key vendors (expensive).

Madhuri Gandikota Replied at 6:04 PM, 9 Jun 2015

Thank you all for the comments and valuable information.

My thanks to Lyndee. You have not only gave a great example but made a business case for me. You exactly told the pain point. If I may I would be very happy to reach you off line and explore how we as a young company can contribute to your need.
We will be more than happy to share our project pilot and see how we can you create value from the these disparate data sources, help optimize the information to act on. Please let me know if this is ok.

Also, my thanks go to Amanda for VA dashboards example and how they help the conversation .

I will be looking forward for great information for the panel questions from the experts who have been the battle field for years.

Yudha Saputra Replied at 6:32 PM, 9 Jun 2015

Dear Marie and colleagues,

Thank you so much for your kindness to invite me into fruitful discussion.
All conversation are really interesting, especially on how can we educate healthcare professional in outreach distance. As I speak here, I may not have resources, but in my opinion, online continuing education would be very valuable to be resources for enrolling clinical practices. It's on my personal experience since I start to learning thorough free Continuing Medical Education (CME), Continuing Pharmacist Education (CPE), and other Continuing Professional Education (CPE), my concern on patient was increased. I also love to talk to my peers on how I interact with experts from around the world through online. They very appreciate the materials that could help them to improve their practice quality.
It may not relevant, but not everyone in my surrounding would like to (apologize to say) concern with CPE, if there's no regulations to bound us. Mostly we do it because the regulation said we must have at least 150 credit point of CPE for 5 years or we cannot continue our practices. It's maybe only my narrow view, but do improvement because they interest, it's really hard to find. Sometimes they just (apologize again) choose to pay the seminar but not attend to the veneu. For the event organizer itself, educating healthcare professional is unavoidable promissing businesses. Since we must always pay for numerous amounts that increased every year, we use most of our free time (outside shift job) to come to building or hotel to attend a CPE. When its located in outside town, more cost are required. Most of them choose their time with family whenever they have free time.
Actually using online method would be worth, but in my personal opinion, it would be very hard to implemented in my country. Simple example, I do a CPE to gain credits, but I use my peer's email and passsword, so the certificates and credits its not mine, but my peers. I know its very humiliating act, but there's dark things often happens in my surrounding. Worstly, these kind of action is increasing every time. But once again, its only my opinion. I don't have documentation proof to prove it. There's various (for me) not good things happen done, but sometimes the reason is salary. Not everyone here guaranteed with proper amount of salary so they can really concern on their practice. Instead thinking about improving care (really apologize again to say), they choose to think about how can they got more salary to keep on living with their family.
Nevertheless, providing free online education for outreach healthcare professional is (in my opinion) very worth to close the gap in their daily practice.

Apologize if there any irrelevant contexts. Hope these discussions will be more interesting!

Lynn Weekes Replied at 6:34 PM, 9 Jun 2015

A word on using clinical record data as we have also had some early experience with this. We have recruited 500 practices to a project called MedicineInsight in which practices allow us to extact de-identified data from their systems in real time (or close to, at the moment its every 1-2 weeks). The data is cleaned and that is no small feat as all the problems Lyndee outlines come into play. Our doctors will often use free text fileds for the diagnosis and in the case of Type 2 Diabetes there were some 100s of synonyms that we had to map. By providing the data in usable formats back to the practice we are building not only great quality improvement opportunities but also a case to improve data quality. At present the data is presented back in a facilitated meeting, all practice staff attend so that systems issues can be addressed and the practices can re-identify the deidentified files so that specific action can be taken for patients. In our jurisdictions, the practice owners are the owners of the clinical data (not patients or vendors) and so our agreements are with them. Patients have the opportunity to opt out of their data being collected at any time. There are currently about 3,500 GPs and 6 million patient records in the database.

Lynn Weekes Replied at 6:48 PM, 9 Jun 2015

And now moving to the second question - this is one that people always ask, in a attempt to establish the credibility and value of the work and test if its all about quality or saving money. Our topic selection is based on a range of inputs and the ultimate decision making of an expert advisory group that we call, Prescribing Intervention Advisory Group. The group membership includes GPs, pharmacists, behaviour change experts, GP educators, consumers, a GP in training, a general practice nurse, a clinical pharmacologist. A similiar group directs activity for the Diagnostic program with more emphasis on diagnostic imaging and pathology expertise. To decide on topics for the year, a planning meeting is held to consider: prescribing trends on the PBS (national third party payer), new drugs that have or are about to be covered by the PBS, new research/evidence/guidelines, evidence of variation in prescribing, safety alerts from the regulator, post-market reviews, interviews and survey data with GPs and practice staff. Potential topics are listed and ranked. At a subsequent meeting the expert committees look more intensively at the formative research that we have prepared in house on specific topics to determine the focus and key messages for the topic. The formative research paper that I received on diabetes recently was about 150 pages. I have attached a quick cut and paste of the table of contents for anyone who wants a clearer idea of what is covered.

Attached resource:

Luis Azpurua Replied at 11:26 AM, 10 Jun 2015

This is a very fruitful discussion. I'm learning a lot from it.

What I see from it is that you are a way beyond from where we are in Venezuela ( and LMIC?). I'm learning the concept of Academic Detailing. We have seen the drug industry's marketing in action but not Academic Detailing (AD). Since we have so many needs to address in our health care system and face a scarce budget, AD services look like a luxury.

Our experience to share knowledge is first to create a network of target people. This is made by face to face meetings. In these meetings the target audience will know who you are, what do you represent and if you have the authority or knowledge to be trusted. People believe in people.

Then we use a mix between delivering information mainly by email and very short and casual meetings in the people's working places (wards, nursing stations, etc.) that we call "pills" to reinforce the information delivered. But this initiative is local, just in one hospital. We need to reach out to nearly 2,500 physicians through our Contry. To do this we have to figure out how to use the technology assisted interaction.

As a comment I was born in the pre- internet era so I learned how to use it. For us the face to face interaction is essential. But the new generation is born clicking computers and interacting with mobile devices. That's part of their life. It's amazing to see them on public places looking down to their mobile devices and paying more attention to them than the surroundings. What about if for this generation interacting with computers / mobile devices is the same as to face to face contact in the former generation?

Finally I Attach an article, not related to medicine, but useful to know how technology is changing the processes by which information is shared and consumed. I hope it would be useful for this community.

Attached resource:

Ellen Dancel Replied at 12:18 PM, 10 Jun 2015

For us at the Alosa Foundation, developing the credibility with our prescribers begins with the process of developing the materials. We identify topics based on evidence updates, or our funder’s preferences. We then host a focus group with prescribers currently practicing in our targeted area to get their perspective on the day-to-day challenges and opportunities for improvement in the topic area. We hold a kick-off meeting with our clinical group: including a select subject matter expert in the topic, our core clinical team and staff. While we will further refine the evidence-based, unbiased educational module, the kick-off meeting outlines the module direction and proposes what we consider to be the core messages of the program. These will be refined to the key messages, of which Amanda gave a great example of yesterday.

The other day one of our detailers shared that after a visit a doctor told her ‘I get more out of a visit from you than I do from all other CME I take a year.’ Despite the data that supports academic detailing, this comment to me highlights two things: 1. We have built credibility with our doctors by providing a consistent, evidence-based, unbiased product that has demonstrated value to their practice. 2. Our relationships, both the detailer-doctor as well as the doctor-organization, are the core of our success.

These relationships take time and of course trust. The quote above was from a detailer who has been visiting her prescribers for about 10 years. We also have programs in different environments. In long-term care conducting multiple visits encompassing multiple staff with a consistent message can also build some of these same relationships as our more established program. Another program we have launched does not have either of these and making the connections and gaining the trust of the prescribers is a much greater challenge.

Bevin Shagoury Replied at 12:59 PM, 10 Jun 2015

Ellen makes a great point above about "the core of success" being directly tied not only to the quality evidence presented, but especially the relationships that are built over time. At NaRCAD, our 2-Day Training sessions seek to provide our trainees, many of whom will be going out into the field to carry out a specific program or intervention, with the skills to really assess the needs of clinicians, meet them 'where they're at', listen to them intuitively, and then provide solutions and support as part of a service (which Amanda so aptly identified academic detailing as.) When we follow up with our trainees a few months or even a year or two out, they tell us that while the clinical materials and topics change, the relationship-building never does, and that the skills they learned at our program are used consistently to proactively support the clinicians they visit one-to-one. As Ellen mentioned, it's about "gaining trust", and that's something that takes time to build, and can be maintained as a great foundation to roll out new interventions and evidence as the partnership continues to grow.

Attached resource:

Amanda Kennedy Replied at 1:07 PM, 10 Jun 2015

To respond to the technology comment made by Luis: “We need to reach out to nearly 2,500 physicians through our Contry. To do this we have to figure out how to use the technology assisted interaction.”

We have been using web-based academic detailing on a limited basis for many years. I know of a few programs in Canada doing this as well. You can use any synchronous technology you like (e.g. Skype, Webex, GoToMeeting, even the telephone!). Each technology has strengths and weaknesses that must be carefully considered. In our experience, the key to success in using web-based academic detailing is having the social relationship in place first and making sure these sessions are one-on-one and not a televised “grand rounds” or webinar. In our program, we often drive 2 hours each way to meet with a provider. We have found that meeting online every other time has worked really well for some of the providers we serve. We show that we truly care enough to make the drive and maintain that personal relationship, but that technology is also a useful tool that allows us to be efficient with our time. Not all providers are willing to participate in web-based academic detailing, so this option is completely voluntary in our program.

Amanda Kennedy Replied at 1:14 PM, 10 Jun 2015

Today’s question: What tools, techniques, or communication strategies are most effective in helping health care professionals adopt best practices? Our program relies on many frameworks to assist in our academic detailing sessions. We utilize concepts from motivational interviewing, adult learning theory, and social marketing heavily in our communication techniques. Handouts, or visual aids, are critical in supporting our conversations. Our tools vary by topic, but we always have some. For example, in our diabetes topic, we bring insulin pens with us to our visits (they are filled with saline and used for training purposes). This allows prescribers to touch and try the devices, lowering barriers to prescribing insulin for appropriate patients.

christophe millien Replied at 2:48 PM, 10 Jun 2015

an assessement is really necessary to know the need in term of meducal education for a population.
after knowing the gap an action and astrategic plan is important in short and long term

christophe millien Replied at 2:56 PM, 10 Jun 2015

One important point is really to see differents importants things to
implement.
Corriculum, evaluation plan, evaluation form, rotation plan etc..

Michael Fischer Replied at 2:58 PM, 10 Jun 2015

On today's question I would echo some of the points Amanda made in post #50 above. Effective academic detailing relies on the principles of social marketing to build a relationship based on trust. Clinical educators need to assess the clinician’s needs through a meaningful dialogue that includes mostly open-ended questions. Lectures may convey facts, but lectures rarely cause members to adopt new behaviors. An academic detailing visit is the opposite of a lecture; the 2-way conversation allows the clinician to talk honestly about his or her challenges, which then allows the detailer to present specific actions that can be taken to support the clinician in effectively addressing those needs. By focusing on custom-tailored, action-based recommendations, academic detailers provide clinicians with concrete actions that they can begin to implement immediately into patient care.

christophe millien Replied at 3:02 PM, 10 Jun 2015

In term of teaching strategy we can see it in differents ways.
Lecture, group discussion, simulation, teaching around the bed , increase
knowlegde base all day practice etc..

Terryn Naumann Replied at 3:32 PM, 10 Jun 2015

To add to Amanda's comments about Web based academic detailing, our service (in British Columbia, Canada) has provided this option for several years with mixed success. Our progam services a large geographical area with 6 months of winter, so that a Web Based option makes sense from a practical perspective. However, while some participants think that it is great to have a "Technology enabled academic detailing (TEAD) session" others will decline this option and prefer to wait several months forwhen the academic detailer can make a trip to see them. To me this speaks again to the value participants place on the face-to-face encounter. In our evaluation of this modality, academic detailers were less satisfied with the sessions even when the participants indicated that the session was valuable, reflecting that the academic detailers felt less connected. Academic detailers also report that the sessions are bit more didactic then they would like especially if the group becomes too large. We still provide Web sessions as an option, but face-to-face is preferred by participants and academic detailers even with a well established relationship.

Lyndee Knox Replied at 6:05 PM, 10 Jun 2015

Madhuri -absolutely. Would love to visit more off line. In response to the question about where do we begin in determining the needs of a program - the short answer is we start where the practice is. We ask them what their pain points are. And build out from there. To do this, we really have to be onsite at least at the start of an intervention. Because the next step is then developing an understanding of what is really happening. There is what people believe is happening, what they tell you, and then what is really actually happening. . We learn the most through the casual "water cooler" discussions. Our PFs spend several visits simply observing, shadowing clinicians, staff, patient visits - to get an on-the ground perception of the practice. We call it organizational "eaves dropping." Invariably, some of the most important information comes from casual "water cooler" conversations. This takes time and physical presence. A great example of this is a practice we were working with that had failed 2 times on empanelment and changes for open access. They'd work with the biggest names in the field. And had tried to implement and fail. They asked our PF if she could help. She said yes and spent the next 3 days simply wandering around the practice observing - everything from front desk clerks, to schedulers, to doing secret shopper calls to the schedulers. What she discovered is that none of the scheduling staff or clerks had been trained to assign patients to a particular team or panel. And those that had some idea they were supposed to do that could not see a patient's assignment on their scheduling/management system. She worked with the practice to correct these problems, get training to staff, improve the IT interface and then incorporate all of this into the practice orientation manual, staff evaluations etc. so that even when current staff left, the new staff would receive the training they needed when they were being on-boarded. Third time was a charm. We

Paul Nelson Replied at 10:25 PM, 10 Jun 2015

Let's assume that our (USA) healthcare industry costs our national economy $2,000 per citizen annually more than it should. What is the data that an academic detailing effort will reduce the hospitalization rate of a practice by 25%, especially its Medicare eligible population? And, is there any consensus that certain types of practice change produce a global improvement to a greater degree than others? Finally, it seems that the basics of "organizational development" are universal. It so, how would this strategy for institutional change be applicable to our nation's entire healthcare industry. If a Primary Healthcare Team of one Primary Physician and 2 mid-level practitioners could, on average, offer health care to 2,000 citizens, its likely that nearly 150,000 Primary Physicians would be required. Assuming 5 full-time equivalent Primary Physicians per clinic, an agent of change strategy would require 30,000 teams. Hmmm!

To close this "stream of thought," I would ask the participants who have direct involvement with academic detailing of physician practices, the following question: what per cent of your clients represent a clinic functioning within a medical school institution? It seems that the character of practice change should be a part of the professional psychic for every Primary Physician when leaving their Post-graduate training. My view of clinical care is that 70% of patient encounters lend themselves to the intent of evidence-based health care. But, the other 30% are harmed by it since the level of uncertainty is so great that using strictly deductive reasoning will not produce a care plan acceptable to the citizen. These events are very difficult for a physician to experience, since they produce a deeply experienced level of inadequacy. At that point, there is a tendency to find counter-productive, mal-adaptive strategies to maintain your connection with the citizen, your staff and, especially, your family. Since there is NO medical education tradition that focuses on professional growth of each physician during training, it is unlikely that the various efforts within the healthcare industry for healthcare reform will be successful. The global question then is: what will it take to achieve equitably available, culturally accessible, justly efficient and reliably effective health care for the HEALTH of each citizen, community by community?

Lynn Weekes Replied at 11:57 PM, 10 Jun 2015

Paul, you raise some big questions that are highly relevant to health policy. A couple of reflections and responses. Our detaling program is provided to 14000 of 22000 GPs in Australia and practices in medical institutions are in the vast minority. It is volunary and GPs receive professional development points toward their annual mandated CPD requirement. You are absolutely right that evidence-based medicine while important does not provide the right clinical care for 100% of patients - that would be assuming we knew all we need to know in medicine. From my perspective the value of academic detailing is that is facilitates the conversation about how to implement evidence but also the conversation about to manage, monitor and communicate with the other 30% of patients. It is all about taking the evidence and tailoring care for the individual patient. Obviously we are operating in a smaller and differently funded health system here but because we can demonstrate direct savings in medicine and test use (2:1 ratio) we continue to be funded to provide outreach for quality care. In terms of the size of the workforce - each full-time equivalent facilitator would see 530 GPs per year.

carol havens Replied at 12:28 AM, 11 Jun 2015

some very interesting questions today and some thought provoking observations. To add to Michaels comments on how to identify needs for academic detailing, we also look at individual practice patterns as well as overall data. If we are not achieving goals (which can be either internal or externally determined ones), we then try to drill down and determine if this is a gap for all providers, or just a few. If the former, we usually try other approaches to reach larger numbers of people first. If however, we find that many providers are reaching goals, but a few are not, we feel this is ideal for an academic detailing intervention. Conversely, if we have a gap that needs to be addressed urgently, we can also use academic detailing to try to recruit those influential physicians who can be leaders in facilitating the change. I agree that providing tools and evidence is critical for both types of conversations-but one of the advantages of the conversations that occur with academic detailing is exploring how clincians make decisions, perhaps in the context of inexact evidence. Sometimes they are guided by whatever evidence exists and sometimes its not-perhaps its because its "what they've always done" or they can't remember to do something different, or they don't have the tools to explain a change to their patients. In these cases, evidence alone may not be persuasive so having more tools in your tool box can be helpful in addressing other barriers. Its also ok to not have all the answers during an academic detailing visit. Offering to get suggestions/answers/resources and get back to the clinician demonstrates their value and the importance of the relationship.

carol havens Replied at 12:35 AM, 11 Jun 2015

I'd also like to respond to the question about how to quantify the ROI of academic detailing. I think its very difficult to prove results on any single intervention since we know it takes multiple interventions before adults change their practices. There is certainly evidence of short term change after an academic detailing intervention (just as there are others which demonstrate little or no change). It may not be scientific, but certainly anecdotally, clinicians report benefit in making changes-there have already been some of these stories posted in this conversation. I think the most successful intervention to facilitate change will incorporate multiple formats and interventions over time. If nothing else, industry continues to use detailing interventions, and they are certainly convinced they work!

carol havens Replied at 12:44 AM, 11 Jun 2015

Because I am so convinced that multiple interventions are more successful, my response to what tools, techniques or communication strategies are most effective in facilitating change would be "it depends". Depends on what the most significant barrier or barriers are. If its a knowledge gap, there are many effective ways to improve knowledge. If it requires a skill to implement, such as a physical skill like injecting a joint or doing a biopsy, observation and practice are required. Same for communication skills which can't be learned by reading or attending a didactic lecture. So accurately determining the barriers should lead to effective interventions.

Paul Nelson Replied at 8:20 AM, 11 Jun 2015

Lynn,

What you describe may be the sole reason why the cost of healthcare, as defined by its portion of a nation's economy, is much lower for Australia than here in the USA, 25-30% less. I get it.

Shimon Waldfogel Replied at 8:23 AM, 11 Jun 2015

Paul Nelson asks an important question that needs to be at the heart of our
conversation about our, global medical/healthcare "system"...

Amanda Kennedy Replied at 9:40 AM, 11 Jun 2015

Thank you Paul for your candid comments (#57) and to Lynn (#58) for responding so eloquently. In Vermont, we offer a voluntary program to all 215 primary care practices. Although our program is much smaller than most, our spirit is very much the same as those in Australia, Pennsylvania, Saskatoon, etc. We try to visit with prescribers (who are mostly physicians) in every county and most of our practices are not affiliated with an academic medical center. While I believe academic detailing is a worthwhile and very important activity, I would never suggest that this is an intervention powerful enough to reach the effect sizes you wish for!

This leads me into our question for today about factors for success and current challenges. In terms of challenges, “proving” academic detailing is a worthwhile intervention is a great challenge at times. Funders rightfully want to know that their money is well spent, but are often unrealistic about what analyses or “proof” can be accomplished within the constraints of the budget they are willing to authorize. I don’t feel there is consensus in our area about what outcomes are reasonable to ask for.

In terms of successes, I find they are deeply personal and individual to our detailers. Sitting with a physician who has an “ah-ha” moment and implements a change is the most rewarding part of my academic detailing efforts (a similar theme was referred to in post #47). Therefore factors critical to success include detailers or educators that are passionate about this work, want to help providers make changes, and have the educational and clinical backgrounds to facilitate these changes.

Michael Fischer Replied at 12:20 PM, 11 Jun 2015

Several of the recent posts have touched on aspects of today's questions, "What factors are critical to the success of outreach education programs? What are some of the challenges you and your colleagues have encountered with implementation?" I can provide some additional reflections on those questions based on our experience at NaRCAD.

In terms of the first question, academic detailing is a service based on the building and maintaining of a trusting relationship between the detailer and the clinician. A successful academic detailing intervention requires great clinical educators who are able to skillfully present strong, evidence-based content. If a detailer were to present messages based on shoddy or insufficient evidence, or messages focused only on cost issues, that detailer would not maintain credibility with clinicians. An expert educator must be comfortable with the principles and techniques of academic detailing, which includes 2-way conversation in which the detailer assesses needs consistently throughout the visit, adapting their presentations in response to the needs and reactions of the clinician with whom they are interacting. Similarly, they must determine in real-time which messages are making the most impact on the clinicians and which messages may require additional review and support. And effective educators must build their relationships with clinicians upon the foundation of trust, using multiple visits to create these lasting relationships over time. When academic detailers can become trusted sources of reliable and practical information and support for front-line clinicians, they can be true catalysts in improving the quality of patient care.

Of course, as the second question implies, there are challenges in implementing effective outreach education programs that extend beyond finding excellent, committed academic detailers. Other implementation challenges include a struggle to find resources: outreach education requires consistent person-time, generally from well-trained health-care professionals such as nurses, pharmacists, and clinicians. There is also the challenge of working with organizations and institutions that may be reluctant to make the initial investment in new programs, even though the gains in improved patient outcomes and reduced excess care can be large. Likewise, for many independent programs, major challenges include access to clinicians. All clinicians are busy, especially those in primary care, and as a result, many layers of “gatekeepers” may insulate a primary care provider from outsiders. Another challenge includes obtaining reliable data to assess the effectiveness of an academic detailing intervention; in the US system where health care delivery is fragmented, obtaining reliable data to assess academic detailing interventions may not always be possible.

Lynn Weekes Replied at 6:43 PM, 11 Jun 2015

Thanks Mike for that great summary of what is critical for success. I would add, being relevant to the context of your health system and its incentives/disincentives is important and why all of our models while at the heart very similar have variations that work for us. Being able to measure impact is also critical as there always seem to be people wanting a cheaper and easier way to achieve results, 'lets just print a brochure', and we need to be able to continually show the effectiveness of multifaceted interventions including detailing.

Madhuri Gandikota Replied at 8:54 PM, 11 Jun 2015

Thanks Lyndee. I am between conferences. I will get in touch with you after 17th. June.

Also, great discussion from all the members.

Thanks

Roar Dyrkorn Replied at 2:34 AM, 12 Jun 2015

Norway calling!
In Norway we are 5.5 million inhabitants, we have about 24.000 MDs where of about 4500 are GPs. We have a 5 year post graduate education to become a specialist in general practice. At the homepages of our health authorities we can find about 5.000 pages of governmental guidelines. One can anticipate that the cardiologist and the nephrologist know the guidelines of their specialty, but it is impossible for a GP to have complete oversight of and to practice all these guidelines fully. Some of my GP colleagues even call it "a guideline-hell"!

I am GP specialist and a clinical pharmacologist at St. Olavs Hospital, Trondheim, and very engaged in AD. We have visited both NPS and NaRCAD to learn the method an our greatest inspirer has been Debra Rowett from Adelaide, Australia and the NPS. She recently visited Trondheim Norway to teach us more about the method. We established a hospital educational outreach in 2006 called "Caring for GPs where are!", where we copied the pharmaceutical industry doing updating visits during lunchtime, but with no lunch.

Now we have done our first real AD-project; "More appropriate use of NSAIDs" among 207 of 227 GPs in our area.
91% of the GPs welcomed the AD-visit. The visits are conducted by the clinical facilitators, clinical pharmacologists/GPs and pharmacists, from pharmacological We who have completed the visits have perceived the doctors that interested and positive in the one-to-one meetings. This is confirmed by the evaluations we have received so far from the participating doctors. Of those who have responded so far (N =1 68) all of them express (100%) that they believe the method is very well or well suited for pharmaceutical information. 91% have responded that they are to a great extent or to some extent are going change their practice after the visit. 98% indicates that it is likely or very likely that they in the future will welcome ADs. I think this is mostly due to the personal one-to-one relationship and that the information comes from a independent evidence based source delivered by a dedicated clinical facilitator.
We are now going to follow prescription rates from the Norwegian Prescription Database and compare results with similar communities over the next year and we hope this will show our health authorities that AD is worthwhile.
I think the contributions from Lynn, Amanda and Mike gives a very good summary of what is the most important about offering AD as a service, assessing GPs needs and how important the dialog is.

Michael Fischer Replied at 12:22 PM, 12 Jun 2015

The question for the final day regards defining success and measuring efficacy. We have begun to get at these questions in some of the discussion thus far, I would add a few more observations:

Success for many academic detailing programs is reflected in the enthusiasm of the clinicians who are educated through an effective, evidence-based intervention. Amanda and others have touched on this in their earlier comments. Within longer-running programs, a successful academic detailer will develop trust-based relationships with clinicians, continuing to present key information in an interactive format so that clinicians can provide the best care for their patients. This type of success can often be captured through surveys of the clinicians and with other qualitative approaches.

When possible, the efficacy and impact of academic detailing programs should be measured quantitatively as well as qualitatively. The ability to do quantitative evaluation will depend on the type and of data available and the reliability of the data. In many settings the full range of health care data to assess an intervention may not be easily available, so evaluators need to think pragmatically. In some circumstances, efficacy can be assessed using process measures, that is, what actions were taken by clinicians (for example did the volume of tests or medications ordered change in the direction suggested by the educational message). This information may be more easily available from existing systems, and can be gathered and assessed more rapidly. Ideally, data and time will allow for the assessment of actual patient outcomes related to the program, but that does demand more resources.

carol havens Replied at 1:33 PM, 12 Jun 2015

since academic detailing is dependent on relationships and repeated contact over time, part of the follow up conversations can be asking about how the most recent recommendations are being implemented. A physicians self assessment of change is a pretty good indicator of actual change. I have found that physicians will actually say if they haven't instituted a new recommendation, and can usually say why as well. Either way, the information is valuable to assess next steps and the efficacy of the intervention. While we would love to have "hard" data on effectiveness, even the assessment of how valuable the clinician found the conversation, or whether or not they are willing (or would welcome) a follow up converstation is a marker of effectiveness. Change starts with small steps and every small step moves closer to the goal.

Robert Morrow Replied at 11:06 PM, 12 Jun 2015

This has certainly been an interesting discussion. Another frame from a mildly different angle about outcomes reflects how we have constructed our peer academic detailing in the Bronx, NY. Using the CONTEXT of detailing as education for implementation and networking, and the CONCEPT that the encompassing objective of health professional education is to measurably improve the health of the public, we have used academic detailing as a method to implement quality projects in communities. These have used different forms, with the backbone being the training of trainers who are clinician peers, and then using them for interventions as varied as domestic violence diagnosis, chlamydia screening, emergency contraception, promoting diabetes registries, and supporting diabetes prevention as well as diabetes self management training. These last two reflect a breakthrough in the peer training approach by reaching across sectors by linking peer education of community residents, to health services peer detailing, to public health projects and health information support.
This is sounding more complex than it is, and only to support two key points:
1) trusted peers can have a remarkable effect on the behaviors of provider teams, patients, and communities, and can be deployed easily and not at great expense
2) hooking education projects to needed health implementation projects can lead to obvious measures of outcomes besides process measures.

Reaching across sectors and institutions has enabled us to use peer detailing and education to move the needle on health outcomes and to lay the foundations for learning networks. We learn about contextual challenges as well as enablers of success, and as is common in implementation, refine our approach with experience. Having community peers work with health professionals also brings wonderful fresh insights.
Bob Morrow

Lyndee Knox Replied at 10:37 AM, 13 Jun 2015

I'm a little late to responding to the final questions. Here is my response to one - what does it take for outreach education to be successful. My answer to this one is fairly short -first off, at LA Net we've found you have to have leadership that is deeply committed to making the change, or someone in the organization with some power that is - we call them the "champion" -without this, nothing we do with practice facilitation/outreach education will be very successful for long. So we spend quite a bit of time establishing a relationship with leadership and creating buy-in -assuming of course they haven't initiated the request for support (oddly most of our work is from the "outside in" right now" -e.g. an outside group like a health plan or federal funder has an agenda or an idea they want to push out and they fund our PFs to recruit and work with practices to make this happen. Ideally, and eventually, the impetus for outreach education hopefully will shift to the practice itself, and they will reach out for the support. Right now this only happens if there is an external financial driver - like the funds to roll out EHRs. So given the fact that the push for change is often external, our PFs have to create buy-in. We do this by listening, trying to "map" the external change goals to things that matter to the practice, and also by using data . Performance reports that show a practice is not performing at the level they thought they were can be very compelling. The second thing we find we need for successful outreach education/PF is a well trained PF. This often means, a PF that knows how to find out what he or she doesn't know -e.g. access resources and info of value to the practice. We've found practices can typically figure out how to implement changes if they take the time and have someone there almost as a human book mark to force them to take this time- but they often don't know "what" to do. One of the most important things our PFs do is "curate" resources and information and best practices for a practice. I was very struck by a Newsweek article several years ago on "Brain freeze" - basically it was describing what happens to the human brain when it is presented with too much information/too many options. The frontal cortex and thinking processes basically short circuit - and no action or decision making ensues. To me PFs help practice stop 'brain freeze' by finding the best of the best. And the PFs do this by linking in to other PFs and by observing exemplar practices. Of course on the other hand, we also run into practices frequently that have the opposite problem -instead of too much information, they have too little. The PFs job is then to get them, again - the best of the best -the "curate" information/models/approaches to best fit their needs and situation. With leadership buy-in and the right information at the right time, we find the practices can move forward rapidly even if they are missing other critical pieces.

Michael Fischer Replied at 10:06 PM, 14 Jun 2015

Thanks again to GHDonline for hosting this panel and thanks to all of the panelists and participants. Please feel free to follow up with additional questions or to contact us via www.NaRCAD.org with further questions about academic detailing and other forms of outreach education.

Jessica Ludvigsen Replied at 9:41 AM, 15 Jun 2015

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Marie Teichman Replied at 1:22 PM, 31 Aug 2015

Many thanks again to our panelists and members who participated in this Expert Panel discussion last June!

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