The test of a new team-based way of treating bipolar disorder was by all accounts a very successful research effort. Two studies, one in the Department of Veterans Affairs and one in a large HMO, both found significant improvements in outcomes, at little or no additional cost, with team-based care. By one year after the end of the studies, not one of the 15 sites that had participated in the two trials had incorporated team-based care into their standard workflows.
It is neither unusual nor new that evidence-based health interventions disappear without being adopted. The field of implementation science has emerged to help remedy that problem.
Scientific evidence, no matter how extensive or solid, is not enough to translate research into practice. This is where implementation science comes in. As Martin Eccles and Brian Mittman explained in 2006 in the first article for the journal Implementation Science, it is “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine routines. practice, thereby improving the quality and efficiency of health services.”
Implementation science has a twofold purpose: to identify barriers and facilitators to implementing specific innovations across multiple organizational levels and stakeholders, and to develop and apply strategies that overcome barriers and enhance facilitators to adoption.
Implementation science has many roots in medical and social science disciplines. The seminal insight came in part from Everett Rogers, a sociologist and communication theorist, in his iconic 1962 book “The Diffusion of Innovations.” Simply put (simply, that is, seen through the 20:20 lens of hindsight), Rogers argued that the adoption of new technologies was fundamentally a social process, and that there is nothing automatic about the uptake of innovations, even when they supported by the strongest scientific evidence.
Addressing the social aspects of adopting healthcare innovations can seem daunting, as there are so many moving parts that can be relevant, from a CEO’s attitudes and priorities to the availability of parking.
Accordingly, models and frameworks guide implementation efforts by identifying relevant processes and organizing data about how things are done – or not done. One such example is the integrated-promoting action on research implementation in health services (iPARIHS, pronounced EYE-pear-iss). It provides a framework that is simple yet comprehensive in its approach.
iPARIHS suggests that successful implementation is a function of four characteristics: the innovation itself; its intended recipients; its social and organizational context; and its facilitation, or efforts to support adoption, typically by internal or external implementation experts.
It would require a chapter to provide an exhaustive description of each of these types of properties. But drilling down into one—the characteristics of the innovation—shows how different the key issues of implementation are from those governing the generation of scientific evidence.
Following Rogers, iPARIHS suggests that seven aspects of an innovation will drive, or delay, uptake:
These criteria indicate that scientific evidence plays only a minor role in the decision to adopt a new innovation, and other approaches are needed besides simply generating more of the same type of evidence or trumpeting it louder and wider.
Funders of scientific research recognize that improving health care needs more than generating evidence, and that implementation science efforts are essential to this task. My former employer, the Department of Veterans Affairs, always conscious of the return on investment for its research dollars, has funded its quality improvement research initiative for decades. Recently, the National Institutes of Health has dedicated funding to promote implementation research, while the Patient Outcomes Research Institute has incorporated implementation science efforts into its proposal requirements. This attention to implementation science is not limited to the United States.
Science as usual is no longer enough.
Implementation science continues to evolve, as illustrated by the continuing history of VA’s team-based care. Using the techniques of implementation science, we were able to implement team-based care for a broad population of individuals with mental health conditions in a randomized trial in VA outpatient mental health clinics, and demonstrated improved clinical outcomes as a result. However, it is equally noteworthy that our follow-up analyzes indicated that when facilitation support was terminated, the clinical benefits were not maintained.
It’s hard to make healthcare systems change, and even harder to keep them changing. Consequently, implementation science continues to evolve and grow. Current cutting-edge implementation science now focuses on achieving system change and sustainability.
Mark S. Bauer is a psychiatrist, professor of psychiatry emeritus at Harvard Medical School, and former associate director of the U.S. Department of Veterans Affairs Center for Healthcare Organization and Implementation Research.
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