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Keywords:

  • organisational development;
  • implementation;
  • irrational pharmacotherapy;
  • drug prescribing;
  • information technology

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

Introduction

The regional Board of Health in Stockholm, Sweden, established the Pharmacotherapy Centre (PTC) to enhance the rational use of medicines. The PTC initiated computerised decision support systems and developed a range of electronic service products to sustain rational prescribing. However, knowledge about which determinants have supported or hindered the sustainability of this type of healthcare organisation is limited.

Objective

This study aims to identify and explore determinants that support or challenge the development and sustainability of the PTC organisation, as well as investigate the key elements of their implementation efforts.

Methods

An in-depth interview study among key informants involved in the establishment of the PTC organisation was conducted. Data were analysed using qualitative content analysis.

Results

Findings suggest that determinants enabling the development and expansion of this organisation include the presence of innovative characteristics among the PTC leadership and the ability of leaders to nurture visionary innovation in others, as well as the instigation of informal social networks and to identify end-user needs. Challenges included an ambiguous relationship to the pharmaceutical industry, an underestimation of the innovation-system fit and to undertake systematic evaluation of created impact by the organisation. Although prescriber use of electronic service products and adherence to an essential drug list increased over time, it remains difficult to identify methods required for demonstrating patient effects.

Conclusion

Whereas some determinants enabled the successful expansion of the PTC organisation, others served to substantially hinder it. The determinants identified can pave the way for systematic investigations into organisational change and development research in the pharmaceutical field. Copyright © 2013 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

Pharmacotherapy, that is, drug therapy, plays an important role in people's health and their quality of life. However, there are increasing concerns with irrational drug use that can result in drug-related morbidity and mortality. These can increase the rate of adverse drug–drug interactions leading to additional cost and waste of valuable resources (Eiermann et al., 2009; Moon et al., 2010). The rapid increase in drug expenditure during the past decade, for example, has placed considerable pressure on healthcare systems (Garattini et al., 2008; Sermet et al., 2010). Countries, such as Sweden, have attempted to address the challenges presented by increased expenditure through instigating a range of national and regional reforms and measures (Walley et al., 2005). ‘Rational’ in this context is defined as ‘patients receive medication appropriate to their medical needs, in doses meeting their own individual requirements, for an adequate period of time and at the lowest costs to them and to the community’ (World Health Organization, 1985).

Organisational development and change is nevertheless complex and multifactorial, influenced by external and internal determinants and moderators (Burke and Litwin, 1992; Greenhalgh et al., 2004). Innovative organisations are, in particular, nurtured when structures are organic and when management has a long tenure, there are available resources and high interunit communication (Damanpour, 1991). The impact of various determinants on dissemination and implementation relating to professional, organisational and environmental characteristics (Greenhalgh et al., 2004) has already been identified. However, because many healthcare organisations achieve only partial reform (Grimshaw et al., 2006), these factors become increasingly important in the development of efficient change strategies, including typically multifaceted approaches used to influence change (Wettermark et al., 2009). At present, it remains unclear about which strategies achieve the greatest change (Grimshaw et al., 2006; Francke et al., 2008).

In recent years, information technology (IT) has provided new possibilities to enhance quality and safety in healthcare, including pharmacotherapy (Eiermann et al., 2009). However, to date, there exists a paucity of examples demonstrating how healthcare organisations systematically adopt the scientific knowledge gained by the use of IT, especially in the effort to improve rational drug use.

The Pharmacotherapy Centre (PTC) in Stockholm, Sweden, provides one example of the region's efforts to implement rational drug use via IT-based support systems.

The PTC organisation has implemented drug guidance and guidelines in both electronic and paper formats with considerably higher adherence rates compared with other countries (Sermet et al., 2010; Gustafsson et al., 2011; Stichele, 2011). Overall, however, insight into factors that can positively or negatively influence the development of such innovative healthcare organisations remains limited, in particular from studies conducted within the pharmaceutical field. In response to this paucity of attention, we aim to identify and explore any important determinants that support or challenge the development and sustainability of the PTC organisation, as well as investigate the key elements of their implementation efforts.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

The study design was approved by the regional Ethics Committee at Karolinska Institutet in Stockholm, Sweden, Dnr 2008/5:5.

Setting

In 1998, drug budgets were devolved from the state to county councils (regions), which allowed for a focused investment of resources for implementing rational pharmacotherapy in that county. This reform also facilitated the development of guidelines and various campaigns targeted at prescribers and patients. Through the development of a range of electronic service products, also concentrated on user-defined needs, such as the Janus Support system and recommended drugs—referred to as the ‘Wise List’ (Box 1). Regular feedback, educational activities and financial incentives have also been instigated to increase adherence to the Wise List (Gustafsson et al., 2011). The PTC has since grown to employ approximately 100 people and supports a network including several hundred physicians, who work in various practices in the region (Gustafsson et al., 2011). Also connected to the PTC are five regional drug therapeutic committees (Godman et al., 2009).

Box 1. Electronic products to support the rational use of drugs developed within the Pharmacotherapy Centre in Stockholm County

Support productFunctionalityYear developed
Janus decision support system/Janus toolbarDrugs presented by therapeutic class with pharmaceutical company-independent guidelines such as drugs recommended by the Regional Drug and Therapeutics Committee, that is, the ‘Wise List’1996–1999
Study on prerequisites for realisation
Alerts for how drugs should be used during pregnancy and during breastfeedingUser group specification
Drug–drug interaction warnings with colour-coded severity ratingsPrototype construction/test
A search tool for adverse drug effects2000
Alerts linked to the patient's drug listPilot test/evaluation
Integrated as a toolbar in the patient medical record2006
Revised into Janus toolbar
Information website www.janusinfo.seAn non-commercial website with drug information written by local independent experts as well as extensive linking to peer-reviewed information1998
Articles presenting the latest news concerning drugs, more complete guidelines than presented in the decision support (Janus) and links to important databases including Cochrane and MartindaleLaunched within Stockholm County Councils intranet
Critical evaluation of new drugs1999
Information on drugs and birth defects and drugs and breastfeedingOpen at a website
Information about drug–drug interactions
Drug utilisation data for feedbackDrug utilisation data for individual practices in flexible reports for feedback on each practice's individual prescribing patterns and adherence to guidelines2001
Wise advice with key recommendations for improvement as well as quality indicators for monitoring adherence and for benchmarking between different practicesElectronical reports on prescribing patterns launched
Written analyses and comments on the utilisation of drugs2009
New software tools
The Wise List for prescribers and publicIssued and launched by the Regional Drug and Therapeutics Committee in Stockholm2000
The Wise List for prescribers.
Consistently contained 200 drug substances for treating common diseases2003
The drugs selected based on their efficacy, safety, suitability and cost-effectiveness, with key questions for critically appraising the inclusion of new drugsThe Wise List for public.
Available in written booklets as well as electronically adapted to the electronica medical records and www.janusinfo.se 
Complete list of all drugs prescribed to a patientThe goal with the project was to produce a solution, which makes all information regarding the drugs, prescribed for a patient, continuously accessible to all caregivers2003
Prototype construction
A proof of concept was that the stability of the technical solutions was continually evaluated as well as user satisfaction with the system2005
Pilot test
However, the difference in information architecture in the legacy systems makes it difficult to integrate the information in a comprehensive and meaningful way leading to project closure2006
The project closed down
Electronic prescribingElectronic transmission of prescriptions from medical records in Stockholm County Council to pharmacies2002
Implementation
All major electronic patient record systems that were in use in the Stockholm County Council should be capable of sending electronic prescriptions to any pharmacy in the area or to a ‘mailbox’ for prescriptions. The mailbox would allow the patient to freely decide at which pharmacy the prescribed drugs were to be picked up2011
More than 80% use electronic prescription
Developed in collaboration with Apoteket AB 
Computerised decision support system for calculation of kidney functionEstimates kidney function using the CockCroft-Gault formula (GFRCG)2006
Creatinine, age, sex and weight are obtained from the computerised medical recordPrototype construction
Dosing recommendations for the most commonly prescribed drugs in primary healthcare, including approximately 300 substances2007
Pilot test/evaluation
Embedded into electronic medical records via the Janus decision support system2012
Developed in collaboration with the Department of Clinical Pharmacology at Karolinska University HospitalPilot test of a renewed version

Data collection

Following purposive sampling for the criteria of having been involved in the establishment of the PTC in 1996, 11 key informants were identified and invited to participate in a semi-structured interview. All interviews were conducted in 2008 at the respective informant's professional office by a research assistant having a medical background. Following individual informed consent, the interviews were conducted in Swedish and audio recorded. Each interview lasted 30–90 min. The recordings were transcribed verbatim, and, where relevant for the purposes of this reporting, translated into English.

The informants comprised four women and seven men and represented mixed professional backgrounds including medicine, pharmacy, politics and economy, in the sectors of academia, drug regulation agencies, pharmacies and health practice. At the time of the data collection, all informants held key positions within Stockholm County Council. A researcher with no association to the PTC selected the final sample to minimise any potential for bias during the interviews, and participation remained voluntary throughout the study. To maintain the focus on informant experiences, we asked each interviewee to reflect freely on the following questions: How would you describe the early development of this organisation? What factors and stakeholders influenced your work? How did the organisation proceed in the relation to the original development plan? How have you been working with the implementation of the knowledge and decision support?

Data analysis

A qualitative content analysis was performed on the transcribed text according to Graneheim and Lundman (2004). After sorting through the text to identify relevant units for analysis, that is, informant responses to the research questions, the analysis began by creating codes and categories that were systematically abstracted to represent the ‘manifest’ aspects of the dataset. This part of the procedure answered the question ‘What?’ about the text content, and each resulting manifest category was then summarised and reviewed to confirm that no data overlapped. An intercoder reliability check was performed independently by three co-authors, representing different disciplinary backgrounds: public health (T. K.), behavioural science (P. B. R.) and the medicine (G. T), to confirm and name the codes and categories. The categories were subsequently further compared for similarities and differences, which helped to validate the final identification of the themes. These themes represent the analytical question ‘How?’ and express the ‘latent’ aspects of the data, that is, the common thread strung through each part of the analytical process. The reporting is composed of citations, which were selected to illustrate the informants' understandings of the categories.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

Table 1 illustrates the nine manifest categories, which are supported by three latent themes: (i) determinants of success in the development and sustainability of the PTC organisation; (ii) the challenges to the existence of the PTC organisation; and (iii) the key elements in implementation efforts of the PTC organisation.

Table 1. Themes and categories related to the development and sustainability of the Pharmacotherapy Centre organisation and the effectiveness of the implementation efforts to promote rational prescribing
  1. PTC, Pharmacotherapy Centre.

ThemesDeterminants of success in the development and sustainability of the PTC organisationThe challenges to the existence of the PTC organisationThe key elements in implementation efforts of the PTC organisation
CategoriesIdea and driving forcesThe ambiguous role of the pharmaceutical industryCommunication and collaboration with healthcare units
Leadership and multidisciplinary teamsSystems readiness to changeMethods to enhance adherence to guidelines
The importance of communicating with decision-makersIndividual resistance among prescribing physicians 
 Lack of follow-up 

Determinants of success in the development and sustainability of the PTC organisation

Idea and driving forces

The informants articulated the combination of clinical pharmacology with new IT as the most powerful aspect of the establishment of the PTC organisation. An additional conception of the organisation was to involve patients in achieving improved drug therapy. This aspect elaborated the considerable changes in society in recent years, which have allowed patients to gain greater responsibility and involvement in their own treatment. For example, ‘And there's now a kind of awareness that we're involved and are helping patients, they are the important people in all of this. And everyone has a responsibility in this’.

One important event mentioned across several interviews was the thalidomide controversy of the 1960s, presented as a driving force behind the development of clinical pharmacology, the addition of drug and therapeutics committees and, ultimately, the PTC: ‘…if you're talking about what laid the foundations, I think it was things like Thalidomide…’

A second important issue was increasing drug expenditures, especially new biologic therapies. Informants relied on their understanding of the national Swedish pharmaceuticals reform (Social Ministry, 1996) to conclude that Stockholm County Council wanted to invest money in these types of therapies. However, with growing resource pressures, it was considered that ‘the time had come’ for these initiatives. For example, ‘An issue that was a catalyst for this was the issue of expenditure…because expenditure runs over and that eventually breaks the budget’.

The Janus decision support system was considered as a significant initiative by the PTC organisation, with the idea starting as early as 1995. The conceptual idea was that healthcare could benefit from the introduction of a computerised support system. Informants articulated that such support systems could provide assistance and encouragement to improve the quality and safety of recommended drug treatments.

Descriptions of the ‘benefit’ provided by these support systems were elaborated across the interviews, as either those benefiting the PTC activities or those benefits that help to explain why the PTC's activities were perceived as successful.

Informants further elaborated the importance of focusing on the issue of drug therapy within one organisation, with benefits described in terms of medical benefits, pharmaceutical benefits and increased efficiency. The support system offered to prescribers', among other things, was described as a learning moment, freeing up time and leading to safer prescribing with independent drug information. Furthermore, it was conveyed that the healthcare unit could save money and make prescribing more evidence-based throughout such systems.

And then we did something I think was pretty unique at that time. We actually went to the healthcare units and asked, What do staff want? And we asked the same thing of doctors in primary care. And what – what emerged at that time was that it had to be fast, it had to be simple and it had to be user-friendly.’

Social networks were considered important in the project's initial phase. The project was initiated, supported and financed largely due to the close contact with managers at the county council. Early on, it was not always entirely clear to the informants about how things should be performed, but there were some ‘unrestricted funds’ available, which could be controlled. The informants consistently articulated that a bold decision was taken to invest in a forward-looking project. They also recognised that, initially, there were also investors who were willing to take a risk on investing both money and their own reputation.

‘…I think it was simply through a social network. That there were people with a vision…’

Leadership and multidisciplinary teams

The informants described the project leader as ‘A visionary!’, that is, one who helped appreciably with the progress of the organisation and has been a driving force with a range of important personal attributes, such as intelligence and creativity. Also of note was this person's ability to take on board an appreciable amount of information and turn it into something specific and integrative for the organisation. Furthermore, this leader's character was described as good at identifying trends and foreseeing future possibilities.

‘…if you're really capable and are able to take on board a colossal amount of signals, that's what intuition is, then you end up doing things righthe's been spot-on in almost all his predictions. It's pretty fantastic.’

Nevertheless, although on one hand, these aspects of leadership were described as necessary to move the organisation forward, on the other hand, the leader's personal image was also described as potentially controversial. This was especially the case within the context of a hierarchical organisation, where people who are capable and passionate often say what they think. Some of the informants described this leadership aspect as awkward and as risky for challenging the status quo in this type of organisation.

Recruiting staff with a combined characteristic of personality and expertise was described as fundamental to the organisation's ability to progress. Most informants articulated the opinion that individuals with the best expertise in their respective areas have been recruited to the project. Further, the informants reflected that few employees were hired without also being perceived as having the ability to inspire confidence. In essence, people have been chosen to join the organisation if they appeared to work well in multidisciplinary teams. The atmosphere in the organisation was described as informal, and mistakes were permitted.

The thing that made it easier was the PTC group's way of workingit was, well, a professional yet fairly informal atmosphere where people are also prepared to take risks, dare to have doubts, dare to say if something isn't possible or if mistakes are made or if there are doubts. And that's all right.’

The importance of communicating with decision-makers

The informants reflected on the likelihood that the PTC was a politically governed initiative and that it was thus important to disseminate information to politicians in order to obtain budgets and guarantee survival. Accordingly, constant support, feedback and political backing were required. Some of the projects had been closed down, even if they were seen as a good investment, simply because the money was not available. The informants articulated their suspicions about it being easy to jettison activities that did not directly come under a political body.

Some informants identified a potential for lack of transparency within the organisation, which appeared to raise doubts about the initiative. For example, certain stages of development and projects were initiated by the PTC without the required support of the county council management. The informants described having to constantly argue in order to ‘protect’ the PTC from the council's competing interests—especially those which the decision-makers deemed as having higher priority. Overall, doubts were raised by those who controlled the funds, especially during times of financial crisis, when the PTC was considered as ‘too comfortable’.

In a political organisation there needs to be an interest and knowledge about what's being done in various units. Activities require constant support, feedback and political backing. If politicians lose interest and don't commission projects, in the end it becomes just a cost item in a column.’

The challenges to the existence of the PTC organisation

The ambiguous role of the pharmaceutical industry

‘…you have to relate to the pharmaceutical industry…’

Informants articulated the relationship between the PTC and the pharmaceutical industry as complicated and multifaceted, and as alternately contrasting competition and dependence. The industry was described as a strong commercial force, which pays very close attention to what the PTC writes, plans and does. Healthcare and prescribers were presented as simultaneously dependent on the industry for keeping them up to date, obtaining supplies on good terms and for participating in clinical trials. The industry was described as often visiting primary healthcare centres and hospital departments to create countermeasures meant to achieve their corporate aims. However, informants reflected on the success of the PTC in making it more difficult for the industry to maintain its network of contacts with doctors. Certain marketing strategies, for example, were called into question because the PTC published contradictory information about certain drugs only a few hours after they were launched. However, the informants reflected that potential problems might evolve between the PTC and county council, when the former are critical of the pharmaceutical industry and the latter are in favour of increased collaboration.

‘…the pharmaceutical industry, for example, gets incredibly annoyed by the PTC. And when these big companies come out with a new product, two hours later the PTC is able to publish information saying – there's only a small amount of evidence for this, so they can't get round the PTC.’

System readiness to change

Information technology development was emphasised as a complex issue because the Stockholm County Council had around 25 different electronically driven medical record systems. The technology required for the Janus prescribing support system was described as far ahead of its time, which had led to the potential for difficulties. Much time was spent developing and optimising the system. Some solutions, for example, the ability to collect drugs at any pharmacy, could not be implemented until 2003. Legislation also hindered certain technical solutions because the sharing of patient-specific information between different databases was not permitted.

The problem was that we were actually far too cutting-edge. The Janus support system and the technology required for this kind of methodologyit was, sort of, totallyit's only just starting to become possible now.’

Individual resistance among prescribing physicians

Resistance to lose power

Despite efforts taken to adapt the knowledge support systems to the needs of users, informants described initial resistance among prescribers to changing their way of working.

‘…there is a lot of resistanceyou shouldn't lose too much of the power that you have. You need both the power and the responsibility. You can't just have the responsibility and let someone else have the power – that's something you want to keep. I think for myself, I make the decisions. But this is also a major issue.’

The new ways of working and the new technology was, to some extent, described as a generational issue, ‘I supervise a number of doctors, and I notice that the younger ones are more used to working with the medium of computers.’ This aspect was articulated as relevant because there presently exist greater requirements on doctors to document the effects of drugs and to report side effects. Such tasks were described as being performed electronically.

Different traditions in primary and secondary care

Informants articulated that accessing primary healthcare centres with PTC information was easier than reaching out to hospitals. In general, a physician or a pharmacist from the regional drug committee was described as being able to successfully visit each primary healthcare centre once or twice a year.

‘…we visit all those that want us to visit, and we generally manage to visit all primary healthcare centres a number of times each year. But with hospitals we have a hard time getting into departments. And that's when, in addition to outreach physicians and outreach pharmacists, we also obtain help from clinical pharmacology laboratory physicians, who carry out visits to both hospitals and within primary care.’

Informants also experienced greater resistance to change within inpatient care than in primary care, with older specialist physicians described as the biggest opposition to adopting the new technology. Traditional differences were further identified as specialist physicians ‘knowing their drugs’ but not having an overall picture of patients' drug therapy. Younger specialist physicians are viewed as a major catalyst in the introduction of new technology.

And it's not easy, because in hospitals doctors think that they can do this themselves, as in, ‘We know best and no one can come and tell us what we should and should not do.’

Abating the power apparently bestowed by tradition, informants cited a number of observational studies that provided evidentiary justification for their efforts to improve the PTC's own understanding of how prescribers worked in hospitals.

‘…or the experience we had from hospital X that you need to be out there and observe, you just have to be out on the wards. How do people work, what problems arise, when is it appropriateeverything to make things easier, in order to, as I said, save time.’

Lack of follow-up

The greatest remaining challenge to the success of implementing electronic information systems and support had to do with documenting the impact of the various measures meant to enhance the rational use of drugs. Informants articulated the continued need to find reliable and robust methods, which can be used to both measure and demonstrate the effects on patients. They relied on published evidence to discuss that attempts have been made to measure adherence to the Wise List before and after implementation of educational strategies, and to correlate improved adherence to the list with reduced costs. The implications of such findings presented similar outcomes, whether patients are prescribed formulary or non-formulary drugs. However, to monitor the cost-effectiveness of financial incentives meant to enhance future adherence to the list and this aspect was concluded as still to come.

The informants further emphasised that additional follow-up was still required for unreliable outcome measures, which had attempted to record the frequency of use and system functionality for such systems as the Janus Support system in Stockholm County. The aspect of use time in relation to optimal need and functionality was thus concluded across the informants as requiring necessary follow-up in future evaluations of the different electronic service products. This aspect can be illustrated by the comment,

‘You can measure the number of visits and how long people are logged in, and so on, but the point is that when people login they often leave the page open so it doesn't give an indication of how much [the system] is being used’.

The key elements in implementation efforts of the PTC organisation

Communication and collaboration with healthcare units

Overall, informants considered it important to cooperate with the heads of hospital units to succeed in reaching out with electronic knowledge support systems in day-to-day clinical work. These key figures were described as essential to the implementation process, along with financial and human resources. ‘We need to sell the idea. So, in part, we want to have the unit Heads on board. They were often quietly positive amidst all the other problems they were dealing with.’

Other key figures were prescribers who seemed to hold a positive attitude towards these services. Further articulated was the idea of not wanting prescribers to view electronic knowledge support systems as ‘top down’ strategy but as an aid to decision-making. ‘…when you're sitting around a table there is a certain amount of pressure and possibly also in a positive sense, if you can create confidence in these recommendations’.

A dissemination process utilising a simple distribution of brochures, which only identify drug information, was considered insufficient as an influence to future prescribing. Instead, informants detailed a much more influential process of providing information, demonstrating the system to healthcare units, and then seeking feedback about prescribing behaviours. The drug therapeutic committees and PTC conducted such major efforts, so that prescribers could understand the value of an electronic prescription decision support system.

Furthermore, when drug therapeutic committees establish training programmes, they usually choose their own, locally established experts to create links between experts and prescribers: ‘And it's also important that it is the same outreach physician and same outreach pharmacist that carries out the visits, so that relationships can be formed with the prescribers, just as the pharmaceutical industry also aims to do’.

Some informants also articulated additional concerns that external marketing has not been successful and has instead become a potential hindrance to future funding. This aspect culminated as ‘…on that point, you could say that maybe we failed in some respects with marketing, in terms of getting people to understand what this was all about’.

Methods to enhance adherence to guidelines

The effects of the various interventions were monitored via the use of prescribing statistics, which targeted feedback for prescribers at the level of the healthcare unit. Informants described that various healthcare units were compared with one another to enhance adherence to the recommended drugs on the Wise List.

Our outreach physicians and pharmacists generate prescription statistics for each primary healthcare centre so that they can be compared with other health centres, which are often when everything comes into focus. And, we have previously had different projects, which have also examined at the individual level as well as for doctors at each primary healthcare centre. That's also very effective.’

Informants also recounted that, ‘we've been given a boost by the purchaser function, which has provided an incentive to adhere to the “Wise List”’. However, they held mixed views on the role of financial incentives to enhance adherence to the list. Some informants articulated this aspect as ‘Big Brother is watching you’ to suggest greater control coming from key financial figures, who hold the purse strings, and to suggest a negative influence, which serves to decrease the prescribers' autonomy.

Other informants maintained that financial incentives are the only effective way to achieve greater adherence to guidance and that handing over responsibility for such costs to the medical profession could be one way to achieve this.

‘…in each case at major hospitals, the only really effective way is to involve the issue of money. In this way they have responsibility for their own budget and they also receive a bonus if they follow the recommendations, but receive less money if they don't. That is how it is, unfortunately, but money is an effective control mechanism. This aspect has actually been easier within primary care’.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

A distinctly influential support factor identified is the innovative leader of the PTC organisation. This figure was also characterised as holding outstanding capabilities for fostering innovativeness in others. This finding is consistent with literature describing the positive relationship between a leader's attitude towards change and an organisation's overall capacity for innovativeness (Damanpour, 1991; Greenhalgh et al., 2004). Similarly, the initial development of the PTC organisation relied on this positive determinant to facilitate a climate that inspired creativity and ultimately optimised flexibility for redeploying resources to nurture innovations (Rogers, 2003; Greenhalgh et al., 2004). Determinants such as communication or how organisations might influence each other in informal networks were not systematically defined within our findings, as shown in other studies on complex organisational innovation (Damanpour, 1991). Nevertheless, our informants considered the instigation of such informal social networks as important for the establishment and development of the PTC.

One unremitting challenge to the development and influence of the PTC was identified as the conflict with the pharmaceutical industry. This is, perhaps, not surprising given the industry's influence on prescribing drugs through company-funded clinical trials, company-sponsored medical education and the considerable resources invested in representative marketing activities meant to influence prescribing decisions (Godman et al., 2008; Spurling et al., 2010). This has impact on our study context, where there is a joint agreement between the Swedish Federation of Pharmaceutical Industry and the local county councils to limit contact between industry and physicians, including the remittance of financial support for meeting attendances (Godman et al., 2009). Nevertheless, the PTC has been criticised by some politicians for not collaborating enough with pharmaceutical companies, which could indicate that the organisation has had some influence in causing the pharmaceutical industry to redirect its marketing efforts towards politicians and other stakeholders. It could also indicate that there is room for continued improvement in current initiatives to, for example, develop guidelines and review models for the introduction of new medicines, including their potential budget impact (Wettermark et al., 2010).

Initially, the PTC underestimated the discrepancy between innovation and the ability of systems to implement this, which presented an important challenge to the so-called innovation-system fit (Greenhalgh et al., 2004). The requirements necessary to create innovative IT system solutions made implementation more difficult with, for instance, concerns about 25 different record systems across Stockholm at time of implementation. This finding is further supported by relevant literature (Rahmner et al., 2009).

Contemporary legislation relating to available electronic products also hampered the introduction of potential technical solutions. This has been helped by recent legislation in 2008 allowing for the sharing of patient-specific information between databases (Governmental bill, 2007/08:126). Remaining challenges nevertheless exist and are identified as the need to include non-electronic medical records in databases and the development of solutions targeting communication between different computer programmes. To date, 15 different electronic medical record systems are still in use across Sweden, which confirms previous findings that organisational readiness at the systems level is of great importance to the successful introduction of change (Weiner, 2009).

Our findings additionally suggest that the lack of ‘innovation-system fit’ has been partially overcome by considerable efforts to establish communication and collaboration between personnel. The leadership of the PTC made use of both formal and planned communication, as well as informal means of communication, in its efforts to influence prescribers to change their behaviour towards more rational drug prescribing. Specific determinants as use of ‘change agents’ and ‘experts’ from the drug therapeutic committees, as well as other such entities holding influence over future prescribing, are essential elements in dissemination and implementation theory (Greenhalgh et al., 2004). The drug therapeutic committees primarily handled formal communication through dissemination of information relating to the Wise List and other specific pharmacology training. For more informal communication, the PTC identified prescribers at every primary healthcare centre who had a positive attitude towards the initiative and were then more able to influence peer opinion. Change agents have been diligent in trying to create a close relationship with prescribers. They have returned year after year to the same primary healthcare centres, which informants considered as very important. This strategy may be one determinant behind the high adherence rates to the Wise List, seen in practice at 87% of drugs used in ambulatory care in 2009 (Gustafsson et al., 2011). This also included on-site demonstrations of the various electronic medical and support systems, which helped reduce complexity (Rogers, 2003). Unit heads at the primary healthcare centres were also engaged because they were viewed as key cooperative figures to ‘get on board’. This approach is endorsed in previous studies, with a lack of management support viewed as a barrier to implementation of innovation (Francke et al., 2008).

The PTC electronic service products generated added value for prescribers in relation to existing practice, which informants described in terms of time-saving and safer therapy. These can be referred to as an innovation's ‘relative advantage’ (Rogers, 2003; Greenhalgh et al., 2004). Relative advantage is considered an important determinant because it is believed to be the single most significant feature for adoption—although it does not guarantee widespread adoption alone (Greenhalgh et al., 2004). Also important is knowledge that support and the electronic products can simplify the work of prescribers as based on the ‘adopters' needs’ (Greenhalgh et al., 2004). This was something the PTC worked with and obtained, partly by repeatedly visiting healthcare units and asking specific questions about their needs. Prescribers were also continuously involved in both the design and implementation of this innovation. According to the literature, early involvement of end-users in design and implementation has been supported as important for a successful implementation (Greenhalgh et al., 2004; Francke et al., 2008).

The informants' articulated that the PTC organisation understood at an early stage the importance of evaluating attitudes towards and effectiveness of the various activities undertaken by the PTC. Qualitative studies were used in the development of the Janus decision support systems for drug prescribing (Eliasson et al., 2006). In these studies, the users' attitudes and understanding of the system were explored. However, further evaluations of the impact of the PTC were difficult to perform because of the complexity of the PTC's activities, which changed over time. This complexity made it difficult to find reliable and robust methods to measure and demonstrate the effects on patients stemming from the PTC and its services to support rational use of drugs. It is evident that the organisation underestimated the need for more rigorous evaluation of the effectiveness of its activities over time.

Methodological Considerations

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

The role of pre-understanding is always important in the interpretation of data and can either be a strength or a weakness. As discussed, to address this, a researcher with no association with the PTC made the sample selection of informants. Discussion of the findings with researchers from the same and other disciplines is a way of dealing with the pre-understandings and also to validate reliability of the findings. We performed intercoder reliability among several co-authors to validate our selection of codes, categories and themes. An additional credibility check of the work is to allow the informants to reflect on the findings (Mays and Pope, 1995). This was achieved by letting two informants reflect on the findings without the possibility of influencing the results. The feedback was that they recognised the content and felt familiar with the findings.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

The results of this study are useful for our understanding of organisational change and development in the pharmaceutical field. Future studies can serve to systematically evaluate how such determinants as a visionary leadership nurturing innovativeness, the relative advantage of the innovation itself emphasising end-users' needs and an extensive communication and close collaboration between the healthcare units enable development and expansion of organisations similar to the PTC. Similarly, we identified several challenges to sustainable growth, including the ambiguous relationship to the pharmaceutical industry, an underestimated innovation-system fit and the potential for limited evaluation of patient outcomes.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

We are very grateful to the participating informants for sharing their time and experience during the interviews. We would also like to thank Dr Lena Ekelius for conducting the interviews.

Financial support is acknowledged from the Strategic Research Programme in Care Sciences (Dnr 87008042) for GT and from Vinnvård (Dnr A2007032). This study was part of a larger research project at the Medical Management Centre and Karolinska Institutet, Stockholm, Sweden, about how innovations are implemented and about how knowledge about implementation can further augment the speed and effectiveness of innovation in health and social care.

BW and PBR are employees of the PTC, that is, the Centre of Medical Knowledge, which is an independent non-profit organisation funded by the Stockholm County Council. The authors have no other conflicts of interest to declare.

Authors' Contributions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References

G. T., M. B., T. K., P. B. R. and B. W. were responsible for idea and planning; G. T., M. B., P. B. R., B. W., B. G. and T. K. for theoretical discussion; Lena Ekelius for data collection; T. K., P. B. R. and G. T. for data analysis; and T . K. , P. B. R., B. W., G. T, B. G. and M. B for writing.

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  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Methodological Considerations
  8. Conclusions
  9. Acknowledgements
  10. Authors' Contributions
  11. References
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