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Interactive online diaries are a novel approach for evaluating project implementation and provide real-time communication between evaluation staff members and those implementing a program. Evaluation teams can guide the lines of inquiry and ensure that data are captured as implementation develops. When used together with conventional evaluation strategies, interactive online diaries allow for an in-depth understanding of project implementation, as well as the challenges program staff members confront and the solutions they develop. Interactive online diaries also can help evaluators address challenges such as self-reporting bias, documenting project evolution, and capturing implementers’ ongoing insights as they develop. These insights might otherwise be lost to the evaluation process. The authors describe the development and use of this online approach in the evaluation of a foundation-sponsored program to improve the provision of preventive care in physicians’ offices. The program included 17 practice-based research networks and their participating primary care practices.

BACKGROUND: Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood. OBJECTIVE:To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings. DESIGN:Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation.PARTICIPANTS: Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty. MEASUREMENTS:Field researchers used observational and interview techniques to collect data on prescriptionrelated clinical workflow, information technology experience, and expectations. RESULTS:Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support. CONCLUSIONS:Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.KEY WORDS: electronic prescribing; medical informatics; qualitative research; health services research.

PURPOSE We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs.METHODS Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness. RESULTSIn-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced diffi culties in implementation and require more study to determine how to optimize integration in practices.CONCLUSIONS Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.