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The authors discuss what they believe to be the 5 core principles the next U.S. president should highlight to advance health care and improve the health of Americans.

A growing number of Americans are living with chronic medical conditions and often require medical care that bridges multiple delivery sites, such as hospitals and primary care clinics (Partnership for Solutions 2004; Bodenheimer, Chen, and Bennett 2009; Schoen et al. 2009; Anderson 2010; Thorpe, Ogden, and Galactionova 2010). Effective coordination is necessary to ensure high-quality care for these patients. In part to promote greater care coordination, the American Recovery and Reinvestment Act (ARRA) of 2009 allocated $27 billion to encourage adoption and meaningful use of electronic health records (EHRs) in the United States (Blumenthal 2010b; Blumenthal and Tavenner 2010). Communication of clinical information for coordination of care across delivery sites is an explicit requirement for “meaningful use” payments under ARRA (Blumenthal 2010a). Other health care innovations such as bundled payments, accountable care organizations, and patient centered medical homes aim to improve care quality in part through facilitating care coordination and a greater reliance on team-based care (Rittenhouse and Shortell 2009; Blumenthal and Tavenner 2010; Shortell, Casalino, and Fisher 2010). Given the ongoing reforms targeting the organization and financing of health care, and sizable federal investment in EHRs, it is important to understand how the organizational environment can influence the EHR effect on various outcomes, including care coordination. The shared use of an EHR across hospitals, specialist and primary care practices, and other provider organizations offers great potential to improve coordination by enabling access to comprehensive, current patient information each time a patient is seen by clinicians. EHRs also provide tools to monitor a patient’s health status and intervene promptly when necessary. However, effective use of the information and tools made available by an EHR requires active communication and teamwork between clinicians. In other words, having the basic infrastructure of an integrated delivery system or shared EHR may be insufficient to improve the delivery of care if clinicians do not make full use of the information or fail to use it when working with other clinicians. There is limited research on the effects of EHR use on care coordination (Graetz et al. 2009; O’Malley et al. 2009) and no evidence on how organizational factors may change this effect. For this study, we focus on the coordination of care across delivery sites, such as when patients leave hospitals and re-enter primary care. These transitions represent a timely area of policy and clinical interest, during which prior studies have found high rates of errors (Coleman et al. 2006). We examined the combined effect of an integrated outpatient–inpatient certified EHR and team cohesion on clinician ratings of care coordination across delivery sites in a prepaid IDS. We used survey data from primary care clinicians collected in three different years (2005, 2006, and 2008), during the staggered implementation of a commercially available, integrated EHR system (2005–2010). We hypothesized that the use of the integrated EHR would result in improvements in all reported measures of care coordination and that the magnitude of the association would be greater for clinicians working in primary care teams with higher cohesion.

Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations.

Background In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care–associated infection (HAI) rates. Methods Statewide computer-assisted telephone surveys of California's general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey. Results Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period. Conclusions Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety.

The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local context-that would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and 90 to 2,700 participating physicians. The sites had varying degrees of experience with performance-based payments; however, all formed collaborative new relationships with payers and created shared savings agreements linked to performance on quality measures. Each organization devoted major efforts to physician engagement. Policy makers now need to consider how to support and provide incentives for the successful formation of multipayer ACOs, and how to align private-sector and CMS performance measures. Linking providers to learning networks where payers and providers can address common technical issues could help. These sites' transitions to the new payment model constitutes an ongoing journey that will require continual adaptation in the structure of contracts and organizational attributes.

Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variations in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

The long received wisdom in the organization design, change, and innovation literature is that “form follows function”. We question this dictum particularly for organizations facing radical, volatile changes such as those occurring in the health care sector. Drawing on examples from England, the United States and, to a lesser degree, Australia, Canada, New Zealand, and Singapore we suggest that changes in form oftenprecedechanges in function. We further suggest that they need to do so in order for the functions to be successfully executed. This is as opposed to past attempts to making functional changes without recognizing the need to first change the organizational form in which the functions are to be carried out. We also discuss the implications of this re-framing for form-function alignment and future research.

This commentary highights the key arguments and contributions of institutional thoery, transaction cost economics (TCE) theory, high reliability theory, and organizational learning theory to understanding the development and evolution of Accountable Care Organizations (ACOs). Institutional theory and TCE theory primarily emphasize the external influences shaping ACOs while high reliability theory and organizational learning theory underscore the internal fctors influencing ACO perfromance. A framework based on Implementation Science is proposed to conside the multiple perspectives on ACOs and, in particular, their abiity to innovate to achieve desired cost, quality, and population health goals.

Background Strategies to enhance appointment access are being adopted by medical practices as part of patient-centered medical home (PCMH) implementation, but little is known about the use of these strategies nationally. Objectives We examine practice use of open access scheduling and after-hours care. Research design Data were analyzed from the Third National Study of Physician Organizations (NSPO3) to examine which enhanced appointment access strategies are more likely to be used by practices with more robust PCMH capabilities and with greater external incentives. Logistic regression estimated the effect of PCMH capabilities and external incentives on practice use of open access scheduling and after-hours care. Subjects Physician organizations with >20% primary care physicians (n=1106). Measures PCMH capabilities included team-based care, health information technology capabilities, quality improvement orientation, and patient experience orientation. External incentives included public reporting, pay-for-performance (P4P), and accountable care organization participation. Results A low percentage of practices (19.8%) used same-day open access scheduling, while after-hours care (56.1%) was more common. In adjusted analyses, system-owned practices and practices with greater use of team-based care, health information technology capabilities, and public reporting were more likely to use open access scheduling. Accountable care organization-affiliated practices and practices with greater use of public reporting and P4P were more likely to provide after-hours care. Conclusions Open access scheduling may be most effectively implemented by practices with robust PCMH capabilities. External incentives appear to influence practice adoption of after-hours care. Expanding open access scheduling and after-hours care will require distinct policies and supports.

The US health care system is in a period of unprecedented change. The threats posed by increasing health care costs and the growing consensus that much of current spending is wasted1 have stimulated a broad array of public and private initiatives aimed at improving care and lowering costs: new technologies, increased investments in patient-centered outcomes research (PCOR), public reporting on the quality and cost of care, pay-for-performance initiatives; and continued efforts to adopt value-based payment models. The health system has responded. For example, the number of accountable care organizations (ACOs) has increased from a handful in 2009 to more than 700 in 2015.

Objective To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers. Data Sources The National Survey of ACOs (N = 269, response rate 66 percent). Study Design We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care. Principal Findings Half of ACOs formally include at least one postacute service, with inclusion at higher rates in ACOs with commercial (64 percent) and Medicaid contracts (70 percent) compared to ACOs with Medicare contracts only (45 percent). ACOs that have a formal relationship with a postacute provider are more likely to have advanced transition management, end of life planning, readmission prevention, and care management capabilities. Conclusions Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management.

We investigate the association between the use of Electronic Health Records EHR core functions in physician practices and medication adherence among chronically ill adults, as well as how patient activation moderates this relationship. Cross-sectional logistic regressions are conducted using data from the Aligning Forces for Quality Consumer Survey and the National Study of Small and Medium Physician Practices 2007---2009. Only 43i¾?% of the practices have a basic EHR. The use of electronic communication and connectivity is positively associated with medication adherence for patients who are highly activated, but the association is negative for less activated patients. EHR based interventions may need to be customized based on patient activation and other factors.

Two Sounding Board articles, by Emanuel et al. and Antos et al., discuss different approaches to controlling rising health care costs in the United States. The editors hope that the range of options presented will stimulate discussion and debate on the best ways to bend the health care cost curve.

Accountable care organizations (ACOs) represent the latest attempt to heal a fragmented and increasingly expensive health care system by fostering integration. Yet there is considerable uncertainty about what the ACO model will mean in practice: what degree of integration will ACOs pursue; how do they propose to achieve it; and how will these aspects differ from what has been tried in the past? Integration is a continuous, multidimensional construct encompassing operational, financial, and social connectedness among groups. Foundational work distinguished three types of integration: functional (systemwide coordination of support functions and activities), physician-system (economic and social linkages between physicians and the system), and clinical (“the extent to which patient care services are coordinated across people, functions, activities, processes, and operating units so as to maximize the value of services delivered”; Shortell et al. 1996, 30). This work indicated that clinical integration is paramount and must be supported by physician-system integration. Fundamental to both is the social dimension; both hinge on effective intergroup (provider-system and provider-provider) relationships. We suggest, therefore, that in order to understand what ACOs might offer, it is essential to consider this new model through a social-psychological lens. The 1990s saw a major push towards vertically integrated systems under single ownership, based on the assumption that, having become part of a single entity, providers across the continuum of care would perceive themselves and behave as such. However, structural change did not create the desired social-psychological change: Despite being nominally part of the same organization, physicians and hospitals continued to see themselves as separate groups with divergent interests, values, and worldviews (Budetti et al. 2002; Fiol, Pratt, and O’Connor 2009). While some integrated systems have achieved exceptional performance, many others have faltered at operational, financial, legal, and—perhaps especially—social hurdles (Crosson and Tollen 2010; Shortell et al. 2000). With the decline of ownership-based vertical integration, attention has increasingly turned to “virtual integration” based on contractual relationships and strategic alliances; yet this, too, has its drawbacks, as it offers less of a social or economic basis for coordinated action (Conrad and Shortell 1996; Robinson and Casalino 1996). ACOs have been heralded as a way to address “deficient” integration (Berwick 2011, 1) without once again demanding that physicians and hospitals adopt radical structural change. In the ACO model, providers across the continuum of care agree to become accountable for a population of patients: if they meet quality targets while saving money, they share in the savings; if they lose money, they may be responsible for the shortfall. This model, designed to accommodate virtual as well as traditional forms of integration, promises a way to coordinate care in less integrated delivery systems—which, while seldom viewed as the ideal, are recognized as the norm (Shortell and Casalino 2008; Fisher et al. 2007). However, whereas the structural, financial, and technical characteristics of ACOs are increasingly well specified (McClellan et al. 2010), it remains unclear what integration means in the context of this new model and especially what it means in social-psychological terms. The ACO appears to be a peculiarly social intervention, using social levers—shared accountability and collective incentives—to encourage new relationships among groups. But do ACOs attempt to create the same sorts of intergroup relationships as vertical integration (albeit through different means or on a longer time frame)? If so, the ACO might be understood as an organizational structure that brings disparate groups together by promoting intergroup harmony and collaboration. Or is there something qualitatively different about the social dynamics that ACOs seek to foster? To illuminate this issue, we examined how implementers actually interpret ACOs as a mechanism of integration. As noted earlier, “integration” is a complex construct, and the term can denote a structural, operational, and/or social reality. However, we purposely maintained a loose definition of integration, as we were less interested in the objective meaning of the concept than in its subjective meaning to participants. The study explored to what extent, and in what ways, implementers engaged with this concept when discussing their nascent ACO.

Context This systematic review provides a synthesis of the growing field of public health systems research related to the structure and organization of state and local governmental public health agencies. It includes an overview of research examining the influence of organizational characteristics on public health performance and health status and a summary of the strengths and gaps of the literature to date. Evidence acquisition Data were retrieved through an iterative process, beginning with key word searches in three publication databases (PubMed, JSTOR, Web of Science). Gray literature was searched through the use of Google Scholar™. Targeted searches on websites and key authors were also performed. Documents underwent an initial and secondary screening; they were retained if they contained information about local or state public health structure, organization, governance, and financing. Evidence synthesis 77 articles met the study criteria. Public health services are delivered by a mix of local, state, and tribal governmental and nongovernmental agencies and delivered through centralized (28%); decentralized (37%); or combined authority (35%). The majority of studies focused on organizational characteristics that are associated with public health performance based on the 10 Essential Public Health Services framework. Population size of jurisdiction served (>50,000); structure of authority (decentralized and mixed); per capita spending at the local level; some partnerships (academic, health services); and leadership of agency directors have been found to be related to public health performance. Fewer studies examined the relationship between organizational characteristics and health outcomes. Improvements in health outcomes are associated with an increase in local health department expenditures, FTEs per capita, and location of health department within local networks. Conclusions Public health systems in the U.S. face a number of critical challenges, including limited organizational capacity and financial resources. Evidence on the relationship of public health organization, performance, and health outcomes is limited. Public health systems are difficult to characterize and categorize consistently for cross-jurisdictional studies. Progress has been made toward creating standard terminology. Multi-site studies that include a mix of system types (e.g., centralized, decentralized) and local or state characteristics (e.g., urban, rural) are needed to refine existing categorizations that can be used in examining studies of public health agency performance.

Evidence of the impact electronic health records (EHRs) have on clinical outcomes remains mixed. The impact of EHRs likely depends on the organizational context in which they are used. This study focuses on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association between EHR use and changes in clinical outcomes for patients with diabetes.Retrospective longitudinal study.We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005-2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects were comprised of 80,611 patients with diabetes, in whom we measured changes in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C).For A1C, EHR use was associated with an average decrease of 0.11% for patients with higher-cohesion primary care teams compared with a decrease of 0.08% for patients with lower-cohesion teams (difference = 0.02% in A1C; 95% CI, 0.01%-0.03%). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher-cohesion primary care teams compared with a decrease of 1.42 mg/dL for patients with lower-cohesion teams (difference = 0.73 mg/dL; 95% CI, 0.41-1.11 mg/dL).Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams.

With the growth and complexity of current challenges such as globalization, health threats, and ageing society, financial constraints, and social and health inequalities, a multidisciplinary public health workforce is needed, supported by new skills and expertise. It has been demonstrated that public health education needs to include a wider range of health related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. In the future, public health professionals will increasingly require enhanced communication and leadership skills, as well as a broad, interdisciplinary focus, if they are to truly impact upon the health of the population and compete successfully in today‘s job market. New developments comprise flexible academic programmes, lifelong learning, employability, and accreditation. In Europe‘s current climate of extreme funding constraints, the need for upgrading public health training and education is more important than ever. The broad supportive environment and context for change are in place. By focusing on assessment and evaluation of the current context, coordination and joint efforts to promote competency-based education, and support and growth of new developments, a stronger, more versatile and much needed workforce will be developed., South Eastern European Journal of Public Health (SEEJPH), Volume II, 2014

The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

Background This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. Methods A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). Results Approximately one third (32.4%) of California's hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. Conclusion Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices.

One way to motivate hospitals to improve patient safety is to publicly report their rates of hospital-acquired infections, as California is starting to do this year. We conducted a baseline study of California's acute care hospitals just before mandatory reporting of hospital-acquired infection rates to the state began, in 2008. We found variability in many areas: For example, 70.1 percent of hospitals said that they were fully implementing evidence-based guidelines to fight infection by methicillin-resistant Staphylococcus aureus, but 22.8 percent of hospitals had not adopted any. Our analysis showed that rural hospitals, many of which lack resources to implement needed procedures, faced the greatest challenges in reporting and improving infection rates. Our findings should be of interest to Medicare policy makers who will implement the hospital-acquired infection performance measures in the Affordable Care Act, and to leaders in the thirty-eight states that have enacted legislation requiring reports of hospital-acquired infection rates. California's baseline data also present a unique opportunity to assess the impact of mandatory and public reporting laws.

Background There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). Purpose To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. Methods During 2006–2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. Results Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006–2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. Conclusions There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

ObjectiveIf patient engagement is the new ‘blockbuster drug’ why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices.DesignQualitative study; 103 in-depth, semi-structured interviews.ParticipantsSixty clinicians and eight managers were interviewed at two established ACOs.ApproachWe interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data.Key resultsInterviewees recognised the term ‘patient activation and engagement’ and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches.ConclusionsWithout understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.

The Patient Protection and Affordable Care Act establishes a national voluntary program for accountable care organizations (ACOs) by January 2012 under the auspices of the Centers for Medicare and Medicaid Services (CMS). The act also creates a Center for Medicare and Medicaid Innovation in the CMS. We propose that the CMS allow flexibility and tiers in ACOs based on their specific circumstances, such as the degree to which they are or are not fully integrated systems. Further, we propose that the CMS assume responsibility for ACO provisions and develop an ordered system for learning how to create and sustain ACOs. Key steps would include setting specific performance goals, developing skills and tools that facilitate change, establishing measurement and accountability mechanisms, and supporting leadership development.

Population aging, rapidly increasing costs of healthcare and the growing burden of chronic disease are challenges to health systems worldwide. To meet these challenges will require new approaches to healthcare delivery and comprehensive population health management. Within the context of healthcare reform initiatives, important innovations in delivery system organization in the United States are discussed. The innovations focused on are the Patient-Centered Medical Home (PCMH), the Accountable Care Organization (ACO) and the Population Health Management System (PHMS) combined with new payment arrangements that reward for health outcomes achieved rather than paying a fee for each service rendered. For each of these innovations, the evidence on its performance, the challenges involved, and the factors that might promote greater adoption and diffusion of successful models are reviewed. Finally, the role played by a country’s political system and its associated culture, structural barriers, size and resources, incentive alignment, and leadership are discussed.

The belief that integrated delivery systems offer better care at lower cost has contributed to growing interest in accountable care organizations. These provider-led delivery systems would accept responsibility for their primary care populations and would have financial incentives for improving care and reducing costs. We investigated this belief by comparing the costs and quality of care provided to Medicare beneficiaries in twenty-two health care markets by physicians who did and did not work within large multispecialty group practices affiliated with the Council of Accountable Physician Practices. In most markets, and after adjustment for patient factors, group physicians affiliated with the council provided higher-quality care at a 3.6 percent lower annual cost ($272 per patient).

This paper measures the extent to which medical groups experience external pay-for-performance incentives based on quality and patient satisfaction and the extent to which these groups pay their primary care and specialist physicians using similar criteria. Over half (52%) of large medical groups received bonus payments from health insurance plans in the period 2006–2007 based on measures of quality and patient satisfaction. Medical groups facing external pay-for-performance incentives are more likely to pay their primary care physicians (odds ratio [OR] 4.5; p

Core competencies have been used to redefine curricula across the major health professions in recent decades. In 2006, the Association of Schools of Public Health identified core competencies for the master of public health degree in graduate schools and programs of public health. We provide an overview of the model development process and a listing of 12 core domains and 119 competencies that can serve as a resource for faculty and students for enhancing the quality and accountability of graduate public health education and training. The primary vision for the initiative is the graduation of professionals who are more fully prepared for the many challenges and opportunities in public health in the forthcoming decade.

There is evidence that health information technology can improve quality, safety and reduce costs but that health care providers needed more information about how to implement these technologies to realise its potential. This paper summarises the research and proposes a theory of implementation based on the research evidence. The second part describes two implementations of electronic medical record systems and compares the theory against the findings of these two case studies. The paper provides implementers with research-informed guidance about effective implementation, contributes to developing implementation theory and notes policy implications for current national strategies for IT in health.

This paper provides an analysis of the structure of the health care delivery system, emphasizing physician group practices. The authors argue for comprehensive integrated delivery systems (IDSs). The jumping-off point for their analysis is the recently published Redefining Health Care: Creating Value-Based Competition on Results, by Michael Porter and Elizabeth Teisberg. The authors focus on the book's core idea that competitors should be freestanding integrated practice units (or "islands in archipelagos") versus IDSs (or "medical homes"). In any case, the authors contend that this issue should be resolved by competition to attract and serve informed, cost-conscious, responsible consumers on a level playing field.

Objectives. To describe an implementation of one information technology system (electronic medical record, EMR) in one hospital, the perceived impact, the factors thought to help and hinder implementation and the success of the system and compare this with theories of effective IT implementation. To draw on previous research, empirical data from this study is used to develop IT implementation theory. Design. Qualitative case study, replicating the methods and questions of a previously published USA EMR implementation study using semi-structured interviews and documentation. Setting. Large Swedish teaching hospital shortly after a merger of two hospital sites. Participants. Thirty senior clinicians, managers, project team members, doctors and nurses. Results. The Swedish implementation was achieved within a year and for under half the budget, with a generally popular EMR which was thought to save time and improve the quality of patient care. Evidence from this study and findings from the more problematic USA implementation case suggests that key factors for cost effective implementation and operation were features of the system itself, the implementation process and the conditions under which the implementation was carried out. Conclusion. There is empirical support for the IT implementation theory developed in this study, which provides a sound basis for future research and successful implementation. Successful implementation of an EMR is likely with an intuitive system, requiring little training, already well developed for clinical work but allowing flexibility for development, where clinicians are involved in selection and in modification for their department needs and where a realistic timetable is made using an assessment of the change-capability of the organization. Once a system decision is made, the implementation should be driven by top and departmental leaders assisted by competent project teams involving information technology specialists and users. Corrections for unforeseen eventualities will be needed, especially with less developed systems, requiring regular reviews of progress and modifications to systems and timetables to respond to user needs.

To assess the extent to which the organizational culture of physician group practices is associated with individual physician satisfaction with the managerial and organizational capabilities of the groups.Physician surveys from 1997 to 1998 assessing the culture of their medical groups and their satisfaction with six aspects of group practice. Organizational culture was conceptualized using the Competing Values framework, yielding four distinct cultural types. Physician-level data were aggregated to the group level to attain measures of organizational culture. Using hierarchical linear modeling, individual physician satisfaction with six dimensions of group practice was predicted using physician-level variables and group-level variables. Separate models for each of the four cultural types were estimated for each of the six satisfaction measures, yielding a total of 24 models. SAMPLE STUDIED: Fifty-two medical groups affiliated with 12 integrated health systems from across the U.S., involving 1,593 physician respondents (38.3 percent response rate). Larger medical groups and multispecialty groups were over-represented compared with the U.S. as a whole.Our models explain up to 31 percent of the variance in individual physician satisfaction with group practice, with individual organizational culture scales explaining up to 5 percent of the variance. Group-level predictors: group (i.e., participatory) culture was positively associated with satisfaction with staff and human resources, technological sophistication, and price competition. Hierarchical (i.e., bureaucratic) culture was negatively associated with satisfaction with managerial decision making, practice level competitiveness, price competition, and financial capabilities. Rational (i.e., task-oriented) culture was negatively associated with satisfaction with staff and human resources, and price competition. Developmental (i.e., risk-taking) culture was not significantly associated with any of the satisfaction measures. In some of the models, being a single-specialty group (compared with a primary care group) and a group having a higher percent of male physicians were positively associated with satisfaction with financial capabilities. Physician-level predictors: individual physicians' ratings of organizational culture were significantly related to many of the satisfaction measures. In general, older physicians were more satisfied than younger physicians with many of the satisfaction measures. Male physicians were less satisfied with data capabilities. Primary care physicians (versus specialists) were less satisfied with price competition.Some dimensions of physician organizational culture are significantly associated with various aspects of individual physician satisfaction with group practice.

BackgroundDatabases of practicing physicians are important for studies that require sampling physicians or counting the physician population in a given area. However, little is known about how the three main sampling frames differ from each other.ObjectiveOur purpose was to compare the National Provider and Plan Enumeration System (NPPES), the American Medical Association Masterfile and the SK&A physician file.MethodsWe randomly sampled 3000 physicians from the NPPES (500 in six specialties). We conducted two- and three-way comparisons across three databases to determine the extent to which they matched on address and specialty. In addition, we randomly selected 1200 physicians (200 per specialty) for telephone verification.Key resultsOne thousand, six hundred and fifty-five physicians (55 %) were found in all three data files. The SK&A data file had the highest rate of missing physicians when compared to the NPPES, and varied by specialty (50 % in radiology vs. 28 % in cardiology). NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES. We were able to confirm 65 % of physicians' address information by phone. The NPPES and SK&A had similar rates of correct address information in phone verification (72-94 % and 79-92 %, respectively, across specialties), while the AMA Masterfile had significantly lower rates of correct address information across all specialties (32-54 % across specialties).ConclusionsNone of the data files in this study were perfect; the fact that we were unable to reach one-third of our telephone verification sample is troubling. However, the study offers some encouragement for researchers conducting physician surveys. The NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and provider insurers.

BACKGROUND The accountable care organization (ACO) is a new organizational form to manage patients across the continuum of care. There are numerous ques- tions about how ACOs should be optimally structured, including compensation arrangements with primary care physicians. METHODS Using data from a national survey of physician practices, we com- pared primary care physicians' compensation between practices in ACOs and practices that varied in their financial risk for primary care costs using 3 groups: practices not participating in a Medicare ACO and with no substantial risk for pri- mary care costs; practices not participating in an ACO but with substantial risk for primary care costs; and practices participating in an ACO regardless of their risk for primary care costs. We measured physicians' compensation as the percentage of compensation based on salary, productivity, clinical quality or patient experi- ence, and other factors. Regression models estimated physician compensation as a function of ACO participation and risk for primary care costs while controlling for other practice characteristics. RESULTS Physicians in ACO and non-ACO practices with no substantial risk for costs on average received nearly one-half of their compensation from salary, slightly less from productivity, and about 5% from quality and other factors. Physicians not in ACOs but with substantial risk for primary care costs received two-thirds of their compensation from salary, nearly one-third from productiv- ity, and slightly more than 1% from quality and other factors. Participation in ACOs was associated with significantly higher physician compensation for quality; however, participation was not significantly associated with compensation from salary, whereas financial risk was associated with much greater compensation from salary. CONCLUSION Although practices in ACOs provide higher compensation for qual- ity, compared with practices at large, they provide a similar mix of compensation based on productivity and salary. Incentives for ACOs may not be sufficiently strong to encourage practices to change physician compensation policies for bet- ter patient experience, improved population health, and lower per capita costs.

Accountable care organizations (ACOs) and hospitals are investing in improving “population health,” by which they nearly always mean the health of the “population” of patients “attributed” by Medicare, Medicaid, or private health insurers to their organizations. But population health can and should also mean “the health of the entire population in a geographic area.” We present arguments for and against ACOs and hospitals investing in affecting the socioeconomic determinants of health to improve the health of the population in their geographic area, and we provide examples of ACOs and hospitals that are doing so in a limited way. These examples suggest that ACOs and hospitals can work with other organizations in their community to improve population health. We briefly present recent proposals for such coalitions and for how they could be financed to be sustainable.

Accountable care organizations (ACOs) have proliferated under the Affordable Care Act (ACA). If ACOs are to improve health care quality and lower costs, quality measures will be increasingly important in determining if provider consolidations associated with the development of ACOs are achieving their intended purpose. This article assesses quality measurement across public and private sectors. We reviewed available quality measures for a subset of programs in six organizations and assessed the number and domain of measures (structure, process, outcomes, and patient experience). Two-thirds of all quality measures were categorized as process measures. Outcome measures made up nearly 20 percent of measures. Patient experience and structure measures made up approximately 8 percent and 7 percent, respectively. We propose further improvements to quality measurement initiatives. For example, programs that reward providers should consider reward size and distribution within the organization. Quality improvement initiatives should consider what encourages provider buy-in and participation and the effects on populations with disproportionate health care needs. As the focus of quality initiatives may change from year to year, measures should be periodically revisited to ensure continued improvement and sustainability. Finally, we suggest quality measures that regulators could use prior to ACO formation or in the year or two following formation.

There are now more than seven hundred accountable care organizations (ACOs) in the United States. This article describes some of their most salient characteristics including the number and types of contracts involved, organizational structures, the scope of services offered, care management capabilities, and the development of a three-category taxonomy that can be used to target technical assistance efforts and to examine performance. The current evidence on the performance of ACOs is reviewed. Since California has the largest number of ACOs (N=67) and a history of providing care under risk-bearing contracts, some additional assessments of quality and patient experience are made between California ACOs and non-ACO provider organizations. Six key issues likely to affect future ACO growth and development are discussed, and some potential “diagnostic” indicators for assessing the likelihood of potential antitrust violations are presented.

We thank those who have commented on our article.1 2 3 Our article had two main aims: to acknowledge that some of England’s health policy leaders see commonalities (as well as differences) between England and the US’s efforts to integrate care, and to share some early learning …

Practice ownership and Medicaid revenue may affect the use of care management processes (CMPs) for chronic conditions and expansion of health information technology (HIT). Using a national cohort of medical practices, we compared the use of CMPs and HIT from 2006/2008 to 2013 by practice ownership and level of Medicaid revenue. Poisson regression models estimated changes in CMP use, and linear regression estimated changes in HIT, by practice ownership and Medicaid patient revenue, controlling for other practice characteristics. Compared with physician-owned practices, system-owned practices adopted a greater number of CMPs and HIT functions over time ( p < .001). High Medicaid revenue (≥30.0%) was associated with less adoption of CMPs ( p < .001) and HIT ( p < .01). System-owned practices ( p < .001) and community health centers ( p < .001) with high Medicaid revenue were more likely than physician-owned practices with high Medicaid revenue to adopt CMPs over time. System and community health center ownership appear to help high Medicaid practices overcome CMP adoption constraints.

The independent Office of the Actuary for CMS certified that the Pioneer ACO model has met the stringent criteria for expansion to a larger population. Significant savings have accrued and quality targets have been met, so the program as a whole appears to be working. Ironically, 13 of the initial 32 enrollees have left. We attribute this to the design of the ACO models which inadequately support efficient care delivery. Using Bellin-ThedaCare Healthcare Partners as an example, we will focus on correctible flaws in four core elements of the ACO payment model: finance spending and targets, attribution, and quality performance.

California’s state government, employers and households are concerned about the future affordability of healthcare. We use health expenditure data from the Centers for Medicare & Medicaid Services’ Office of the Actuary to forecast California’s health expenditures from 2013 to 2022 and identify factors driving expenditure increases. Real health expenditures per capita (2013$) are forecasted to increase from $8,398 to $11,421 (or 36%), resulting in health expenditures increasing from 14.5% to 16.0% of California’s economy. Expenditure increases are mostly driven by gains in real income per capita (40-60%), followed by medical-specific inflation (23%), an aging population (14%), and insurance coverage gains (8%). The -4% to 16% residual is attributable to changes in the volume and mix of services and technology. Several innovations could potentially dampen these increases, such as shared-risk, value-based payment models, practice redesign initiatives, lower cost settings and healthcare professionals, many of which are found in accountable care organizations.

Many patients who use tobacco have never been encouraged by their healthcare providers to quit. In recent years, incentives have been provided for medical practices to incorporate tobacco-cessation processes into routine care. This study examined growth in use of these processes as well as organizational and policy factors associated with their implementation.Data from three National Study of Physician Organizations surveys fielded in 2006-2013 were analyzed in 2014. The analyses estimated multivariate longitudinal and cross-sectional linear regression models to assess the relationship between implementation of cessation processes and change in practices' characteristics and external incentives, including state mandates for tobacco-cessation coverage.Systematic identification of patients who use tobacco increased in large (26% to 91%, p0.0001) and small-medium practices (69% to 83%, p0.0001). Neither routine advice to quit nor referral to counseling and guideline-based point-of-care reminders increased. Practice feedback to physicians on their use of cessation interventions increased (18% to 29%, p0.0001) for small-medium practices. State-mandated coverage was associated with the use of cessation processes in small-medium practices (p0.0001), as was pay for performance participation (p0.0001); public reporting (p0.0001); Medicaid revenue (p=0.02); and practice size (p0.0001). Among large practices, predictors were practice size (p0.0001); hospital ownership (p=0.004); public reporting (p=0.03); and primary care practice (p=0.04).The findings suggest that state-mandated coverage for tobacco-cessation treatment and increased use of external incentives such as pay for performance and public reporting programs may improve care for patients who use tobacco.

Article-at-a-Glance Background It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm , proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward? Methods Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting. Results Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided. Conclusions Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.

Evidence of the quality gap between best practice and the current reality of everyday medical care is widely documented and acknowledged (Institute of Medicine [IOM] 2001a, b, 2002, Leatherman and McCarthy 2002; McGlynn et al. 2003). Two IOM reports, Crossing the Quality Chasm (2002) and Leadership by Example (2001a), link the defects in quality largely to system problems rather than individual errors or actions. These reports have helped to focus attention on the need to identify the characteristics that differentiate high-performing care delivery systems from those that do less well. Studies to assess variations in care processes, costs, outcomes, and patient perceptions of care across organizations and delivery system types have not been conclusive or consistent in determining whether one type of delivery system or care delivery organization delivers higher quality or lower cost care than others (Scitovsky and McCall 1980; Nobrega et al. 1982; Miller 1992; Himmelstein et al. 1999; Miller and Luft 1994, 2002; Singh and Kalavar 2004). Shortell and Schmittdiel (2004) suggested that organized delivery systems, especially large, multispecialty practices, characterized by patient-care teams, defined patient populations, aligned financial and payment incentives, partnership between medicine and management, information technology, and accountability, have the potential to provide superior performance in terms of clinical quality and safety although they concluded that studies have yet to demonstrate superiority in the quality, efficiency, or costs of care. Casalino et al. (2003a) demonstrated that physician organizations with strong external incentives, clinical information technology, substantial health maintenance organization (HMO) penetration, a high percentage of patients with utilization management delegated to the group, and owned or affiliated with a hospital, health system or health plan used more recommended care management processes (CMPs), which have been shown to be linked to higher quality care (Wagner et al. 2001). Shortell et al. (2005) found that high performing physician organizations were significantly more likely than low-performing physician organizations to engage in formally organized quality improvement initiatives and external reporting of quality data. Chuang, Luft, and Dudley (2004) posited that health plans affiliated with group- or staff-model delivery systems deliver higher quality care than other plans because of greater integration across specialties and sites of care; decreased conflict among clinical protocols; more consistency of incentives and goals; and larger scale and more stable enrollment populations. Other studies (Levin 2001, Casalino et al. 2003b) indicated that group practices provide more recommended treatments for chronic disease and have lower mortality rates from congestive heart failure and other disease. On the other hand, a study (Baker et al. 2004) of health plans in California concluded that the impact on Healthplan Employer Data and Information Set (HEDIS®)-based quality scores could be owing to more efficient administrative and data reporting systems than to what the physicians themselves did. The study was not conclusive about the impact of the physician group on quality scores. Similarly, existing evidence comparing patient perceptions of care in health maintenance organizations (HMOs) with those in fee-for-service settings is mixed (Miller and Luft 2002, Roohan et al. 2003; Lin, Xirasagar, and Laditka 2004). It should be noted that most existing research on patient perceptions of care does not separate HMOs by the type of delivery system used to deliver care. In the present study, we examine whether the extent to which a health plan utilizes a staff or group model of care delivery is associated with better clinical performance and patient satisfaction. We also examine other organizational characteristics, including geographic location of the plan, affiliation with a national managed care firm, and for-profit status, that may be associated with the performance of health plans (Himmelstein et al. 1999, NCQA 2004).

PURPOSE It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations. METHODS The relationship between measures of primary care orientation and the CCM was examined in a sample of 957 physician organizations from the National Study of Physician Organizations, a cross-sectional telephone survey of all US medical groups and independent practice associations with 20 or more physicians (response rate, 70%). RESULTS After adjusting for potential confounders, 6 of 8 measures of primary care orientation were associated with physician organizations’ adoption of 11 elements of CCM chronic care management. These 6 measures were severity of chronic illness treated in primary care, health promotion activity, health education activity, any accepted financial risk for hospitalization, required reporting, and presence of an electronic standardized problem list. Presence of an electronic medical record and the 5-year primary care physician turnover rate were not associated. CONCLUSIONS Organizations that have adopted 6 core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices. Policy makers and other stakeholders may wish to focus on creating an improved primary care home in their quest to close the “quality chasm” in chronic illness care.

HEALTHCARE EXECUTIVES, working with their clinical teams, need to use the best available evidence to ensure that care is safe, effective, efficient, timely, patient-centered, and equitable-the six aims of any health system as outlined by the Institute of Medicine (2001). Kovner and Rundall provide further evidence that this does not occur as frequently as it should. They go on to identify various sources of evidence that could be used, describe normative models for such use, and provide some useful suggestions for improving the use of management research evidence in the decision-making process. In this commentary, I call attention to the importance of knowledge brokers, discuss the new types of evidence that managers will need to draw on, highlight the importance of governing boards, and offer some specific recommendations for expanding the use of evidence-based managerial research. Figure 1 provides a simplified model showing two pathways in which evidence-based management research might be used by healthcare decision makers. The first pathway depicts the direct relationship between the producers of the research and the users. Recommendations to the research community (Canadian Health Services Research Foundation 2000) have included: 1. Exorting researchers to involve the users early on in the research process; 2. Encouraging researchers to provide preliminary findings in time to be useful to decision makers; 3. Writing the results in clear, understandable language; and 4. Making in-person presentations explaining what the findings mean for practice. In the feature article, Kovner and Rundall also offer several suggestions to improve the organization's use of evidence-based management research including designating specific individuals within the organization to routinely summarize relevant literature, developing a "questioning" culture, linking compensation to use of research, and participating in management research. However, Kovner and Rundall suggest that this direct pathway from producer to user may be of limited utility as managers report getting much of the information that they use in decision making from talking with consultants and others, and through the Internet, conferences, and related sources (see pathway 2 in Figure i). These entities might be called "knowledge brokers." Thus, a more effective approach to improve the use of evidence-based management research in healthcare decision making might be to strengthen the second pathway operating through the knowledge brokers. This will require a stronger connection between the research community and knowledge brokers on the one hand and between the knowledge brokers and the users on the other hand. Simply put, researchers are likely to get more traction in influencing managerial decision making by working with consultants and thought leaders, making conference presentations, and speaking with the media (both print and video), supplemented by posting the findings on the Internet. Disadvantages to this approach include the likelihood that, to some extent, the knowledge brokers may misinterpret the study findings, exaggerate their applications, or claim them as their own. It has been my experience and that of other investigators with whom I have spoken that developing ongoing relationships with targeted respected consultants, thought leaders, and reporters minimizes these potential disadvantages. Careful cultivation of these relationships can create a "tipping point" in which research emerges in the world of practice as "something to pay attention to" and as "ideas in currency." Healthcare executives begin to draw on the findings and data in making decisions and in rationalizing decisions after they are made. To strengthen the pathway between the knowledge brokers and healthcare decisionmaker community requires forums in which these parties can dialog. Research is always context-specific such that the results always need to be adapted to specific environments and to specific organizations, which almost always differ from the environment and organization that participated in the research. …