DIFFUSION OF INNOVATION BEYOND THE TIPPING POINT:

The Case of the Regional Cancer Program Formulary Software

Michelle Goulbourne

Goulbourne Research and Consulting

i-Society 2007Merrillville, Indiana, USA

Overview Describe the development and deployment of the Regional

Cancer Program Formulary Software (RECAP-FS).

Summarize results of an interim survey and web statistics.

Discuss the impact of each the following variables on the rate of RECAP-FS adoption: (i) characteristics of the innovation, (ii) the number of people involved in the innovation decision, (iii) communication network structure (iv) cultural context and (v) promotion efforts.

Assess the importance of key ‘agents of change’ in taking RECAP-FS beyond the tipping point to the level of cultural change.

Share lessons learned.

What is a Formulary? In Ontario, oncology formularies contain the systemic

therapy regimens approved for use for cancer patients. Regimens are based on published Cancer Care Ontario

Clinical Practice Guidelines (Formulary) and institutionally approved treatments that are supported by evidence (Non-formulary).

The formulary when compiled usually takes the form of a printed handbook.

Despite best efforts once printed, these paper formularies are soon out of date.

The process of keeping the regimen details up to date is a labour intensive process involving almost all clinical pharmacist s.

Collaborative Formulary Maintenance

Dynamic reciprocal relationship

DST Chairs and Coordinators

PharmacyFormulary and Therapeutics Committee

11 DSTs

CCO Guidelines

BRCN

GI

GU

GY

HN HE

LU

ME

SA

SK

The Formulary Updating Process

Disease Site Team Based Model

RECAP Formulary

Pharmacist 3 Pharmacist 4Pharmacist 1 Pharmacist 2 Pharmacist 5

GY GI

Formulary and Therapeutics Committee

BR LU SK Other

Previous Formulary

Quality GapIn Oncology pharmacy services, a quality gaps is said to have existed because pharmacy services did not have the tools they need to:

1. Translate guidelines and clinical processes into regimens in an efficient way (5 pharmacists involved in the updating process), and

2. Disseminate this information to staff, patients, families and other stakeholders in a timely, cost effective way.

When quality gaps exist time is spent searching, checking, re-doing and/or waiting.

These gaps in quality prevent us from; 1) enhancing the quality of evidence and its use, (2) providing appropriate patient centered care, (3) improving patient health status and outcomes, and (4)ensuring health system sustainability and equity.

Quality gaps prevent us from creating value.

Innovation

An innovation is an idea, practice, or object that is perceived as new by an individual or other unit of adoption…The perceived newness of the idea for the individual determines his or her reaction to it. If an idea seems new to the individual, it is an innovation. (Rogers, 2003, p.12)

Diffusion

The process by which an innovation is communicated

through certain channels over time among the members of a social system. Diffusion is a special type of communication concerned with the spread of messages that are perceived as new ideas. (Rogers, 2003, p.35)

Why create the Regional Cancer Program Formulary Software?

Why Innovate?

Why Create RECAP-FS?

Automate the process of editing, updating, exporting, archiving and printing chemotherapy regimen information.

Add efficiency and cost effectiveness to the process of disseminating regimen information in a timely manner.

Enhance oncology community access to the latest regimen information.

Enhance patient care. (e.g. Booking clerks will have a up-to-date resource to check nursing times enhance patient/work flow.)

For our customers as well as ourselves.

Creating Value

Value

“…should occur in the prevention, diagnosis, and treatment of individual health conditions. It is at this level that true value is created – or destroyed – disease by disease and patient by patient. It is here where huge differences in cost and quality persist. And it is here where competition would drive improvements in efficiency and effectiveness, reduce errors and spark innovation.”

Porter and Olmsted Teisberg, 2004

Creating Value in Operational Terms

Infrastructure needs to be in place that will allow us to take full advantage of the potential of information, evidence and ideas in the health care system.

Need information management and technological systems in place that will facilitate improvements in our ability manage the potential benefits of health care technologies.

“…give health care providers access to the latest and best information on new treatments or drugs, improve the quality and safety of care within the health care system, and most importantly, empower patients to maintain their own health.”

Commission on the Future of Healthcare, 2002

Systems Perspective

Strategic Drivers

Electronic Formulary to Enhance Quality

The Regional Cancer Program Formulary Software (RECAP-FS) is just one example of a project that seeks to help close this particular quality gap in oncology.

System Drivers

Increase EBCPG use in Regimen Creation

Increase guideline adherence

Manage Costs

Local Level Goals

1. Facilitate the provision of the best available evidence based clinical care

2. Enhanced patient status and outcomes

3. Contribute toward health system sustainability

Annual Expenditures and Number of Approved Drugs for the New

Drug Funding Program 2000-2006*

$42

$52$59 $63

$83

$133

$0

$20

$40

$60

$80

$100

$120

$140

FY00/01 FY01/02 FY02/03 FY03/04 FY04/05 FY05/06

Millio

ns

Year

1414 16 16 18 18

Percentage of Stage 1 and 2 Lung Cancer Patients Treated with

Systemic Therapy in Accordance to Evidence

Made Available by CCO, Mid-2004**

86%

95%

50%

100%

84%

100%

91%

0%

20%

40%

60%

80%

100%

All centres Centre A Centre B Centre C Centre D Centre E Centre F

Cancer Centres

Patient Centric Approach

Creating RECAP-FS

Patient Centric Model

DST

Disease Stage

Formulary Regimens

Efficient Resource UtilizationStandardized Care

Enhanced Patient Safety

Enhanced Quality of Patient Care

Enhanced Patient Outcomes

BR

CN

GI

GU

GY

HN

HE

LU

MY

SA

SK

Patient Factors determine placement within

a disease site based treatment framework

where disease management is based on

stage. For example, in the Breast disease

site group assessment decisions are made

for surgery, adjuvant radiotherapy, adjuvant

systemic therapy, etc.

Medical Care

Processes Factors are

documented in detailed

paths.

Outcomes

Analyses are

facilitated as

patient medical

factors and

process factors

are

documented.

Detailed Care Paths

These process factors are

the major care steps that are

needed to facilitate desired

medical outcomes.

Medical Care Process Factors

Project Schedule

Phase IPhase II

Phase III

Apr 2003 –Feb 2004

Mar 2004 -Dec 2004

Dec 2004 -Aug 2005

Phase IV

Nov 2005 –Dec 2005

-April 03 project starts

-1st Beta arrived July 03

- Aug 03 to Feb 04

Database population

-March 04 Test Survey

-May 04 Regimen Review

-Completed database update.

- Dec 04-Jan05 Training sessions

- May 05-Aug 05 Beta Testing

- Nov 05 Launch Handbook, Software and Icons

Beta Testing

Building Capacity, Developing an Oncology Community

More than 40 staff from HHS and our community oncology locations participated in the software testing process.

Beta testing served many purposes:

1. It engaged clinical and non-clinical staff at all levels in the software creation process.

2. Provided the mechanism through which post-go-live clinical champions were developed.

3. Increased staff knowledge about technology and practical computer skills.

Tester CommentsTester comment on the design, utility and functional specifications of RECAP-FS® prior to its formal deployment directly contributed to the success of this initiative. A few comments from beta tester evaluations are below:

“Well laid out and functional.”

“I learned more about computers in the past hour than I have in the past few years…”

“Not only will I be able to access up-to-date info faster, so will physicians.”

“Information will be accessible on the computer, where I do most of my work.”

Introducing RECAP-FS

A Quick Tour

RECAP-FS® is used to create regimens for chemotherapy or combined modality

treatments. Produce a preformatted formulary for publication with the click of a button.

Generate dynamic reports containing a few or all of the variables in the database.

RECAP-FS Main Menu

Cancer Regimen Information

CCO Guideline RECAP-FS GeneratedFormulary

e-Health Desktop Icons

The Regional Cancer Program e-Health Desktop Icons Software installs three oncology information tools on the users computer desktop.

Once installed, this software gives users immediate access to an always up to date e-Book Formulary, over 160 Medication Information Sheets(MIS) and over 200 Systemic Treatment Record summaries (STR).

Closing the Quality Gap With RECAP-FS

The RECAP-FS project was completed in the fall of 2005.

The software stores over 200 active formulary, non-formulary and clinical trial regimens in its database.

1000 handbook sized copies of the Formulary were printed and distributed to staff across the Cancer Centre, Hamilton Health sciences and community oncology satellite locations.

This project suggests that technological innovations such as RECAP-FS® can facilitate the development of positive and sustainable changes in the culture and practice of health professionals.

Web Statistics

2006-2007 Pharmacy Services Web Statistics

0

200

400

600

800

1000

1200

1400

1600

1800

Systemic Treatment Record Medication Information e-Book Formulary RECAP-FS

Web Page

Vis

its

Mar-06 Apr-06 May-06 Jun-06 Jul-07 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07

2 click access to information 3 or more clicks to access information

Changes at the cultural level, that see staff regularly access and use formulary resources, have a positive impact on patient safety and the quality of patient care.

Summary Using RECAP-FS® to generate online treatment information such as

the Regional Cancer Program e-Book Formulary and other free online treatment information has allowed the Cancer Centre to share evidence based best practices with patients, students, and clinical staff within the global oncology community.

Since its formal implementation in the fall of 2005 more than 600 users across Hamilton Health Sciences and the community oncology affiliates have access to the latest oncology information via RECAP-FS® and the RECAP e-Health Desktop Icons Software.

Transitioning from novelty to sustained changes in day-to-day clinical practice is an important task. Usability has been an important factor contributing to the use of some of the tools to access information. Each month over two thousand hits are registered on the RECAP website pages

and 90% of hits are linked to the pages that are accessed via the two-click informational icons.

Tipping Point

The Tipping Point is that magic moment when an idea, trend or social behavior crosses a threshold, tips, and spreads like wildfire.

Gladwell, 2000

The Clinical Champions

Administrative Change Agents

Change Agents-> Leading us Beyond the Tipping Point

Online SurveyEvaluations completed one year after implementation suggest that the Regional Cancer Program Formulary Software (RECAP-FS®) and the RECAP Desktop Icons Software both play important roles in:

1. Helping pharmacy services attain their goal to disseminate best practices in a way that helps to ensure the equitable and consistent provision of high quality cancer care.

2. Providing information in a timely way so that healthcare teams can work more effectively towards enhancing patient safety and outcomes.

User Evaluations- 1 Year after Implementation

Despite the promotion of electronic health information 52% of respondents indicated that they preferred the printed handbook formulary.

46% of respondents reported that they consulted the printed formulary every day.

81% of respondents received email updates announcing new regimens were online.

46% reported reviewing the regimens online and 36% printed or saved the regimen file.

64% reported that the RECAP-FS tools have had a positive impact on the way they perform their work.

Beyond the Tipping Point The Regional Cancer Program Formulary Software (RECAP-FS®)

project sheds light on factors that impact on a tools rate of adoption and sustained clinical use over time.- Early staff involvement in the project and, the development of lead staff across sites

is critical in developing tools that meets and exceeds staff practice needs.

The transition of an electronic tool from novelty to sustained changes in day-to-day clinical practice is an important goal. - Usability is an important facilitator in this process. During the first year of

implementation over two thousand hits were registered on the RECAP website pages each month.

- 90% of the web hits were to pages that are accessed via the two click informational icons.

This project suggests that technological innovations such as RECAP-FS® can facilitate the development of positive and sustainable changes in the culture and practice of health professionals.

Changes at the cultural level, that see staff regularly access and use formulary resources, have a positive impact on patient safety and the quality of patient care.

Key Learnings

1. Staff capacity building is needed for system change.

2. Develop clinical leaders during the course of the project to enhance the likelihood of successful multi-site software implementation.

3. Regional e-Health initiatives can have a positive region-wide as well as a global impact. This potential needs to be considered and incorporated into project goals.

Thank You

References

Commission on the Future of Health Care (2002). Building on Values: The Future of Health Care in Canada. Ottawa: Government of Canada.

Gladwell, M. (2000). The Tipping Point. New York, Time Warner Book Group.

Rogers E. (2003). Diffusion of Innovation, Fifth Ed., New York, The Free Press.

Porter, M. E. and E. Olmsted Teisberg (2004). Redefining Competition in Health Care. Harvard Business Review.