R. Karl Rethemeyer

The 2007 U.S. National Institutes of Health EPR-3 guidelines emphasize the importance creating a provider-patient partnership to enable patients/families to monitor and take control of their asthma, so that treatment can be adjusted as needed. However, major shortfalls continue to be reported in provider adherence to EPR-3 guidelines. For providers to be more engaged in asthma management, they need a comprehensive set of resources for measuring self-management effectiveness of asthma, which currently do not exist. In a previously published article in the Journal of Asthma and Allergy, the authors conducted a literature review, to develop a holistic framework for understanding self-management effectiveness of pediatric asthma. The essence of this framework, is that broad socioecological factors can influence self-agency (patient/family activation), to impact self-management effectiveness, in children with asthma. A component of socio-ecological factors of special relevance to providers, would be the quality of provider-patient/family communication on asthma management. Therefore, the framework encompasses three key constructs: (1) Provider-patient/family communication; (2) Patient/family activation; and (3) Self-management effectiveness. This paper conducts an integrative review of the literature, to identify existing, validated measures of the three key constructs, with a view to operationalizing the framework, and discussing its implications for asthma research and practice.

Hating America – and targeting or killing Americans – at times seems like a mandatory activity for terrorists, yet only a small minority of known terrorist organizations target or attack American interests. Under what circumstances do terrorist organizations choose to target American citizens and interests? When do they actually commit such attacks? To answer these questions, we leverage data from the Memorial Institute for the Prevention of Terrorism’s database on terrorist organizations and attacks. Our statistical analysis finds that the factors that drive an organization to target US interests are not completely co-terminus with those factors that help to explain the pattern of actual attacks. The propensity to target and to attack US interests are both related to alliance connections and basing of US troops in authoritarian countries that host a given terrorist organization.

Background: In fall 2016, a 2-year grant was secured to pilot a Social Knowledge Networking (SKN) system pertaining to Electronic Health Record (EHR) Medication Reconciliation (MedRec), to enable Augusta University Health System to progress from “limited use” of EHR MedRec technology, to “meaningful use” (MU). A total of 50 “SKN users” (practitioners), participated in discussing practice issues related to EHR MedRec, over a 1-year period. These discussions were moderated by five “SKN moderators” (senior administrators). The pilot study, completed in fall 2018, found that inter-professional knowledge exchanges on the SKN, enabled several collective learning (“aha”) moments to emerge. These learning dynamics in turn, were associated with distinct improvement trends in two measures of MU of EHR MedRec technology, identified for the study. A key takeaway was that an SKN could be a valuable tool in enabling MU of EHR MedRec technology. Purpose: The study’s key findings related to the content and dynamics of inter-professional knowledge exchange on the SKN system, and their association with trends in measures of MU of EHR MedRec technology, have been described in a separate publication. This paper seeks to describe the structure of inter-professional knowledge exchange (or the pattern of connections) related to EHR MedRec, over the 1-year SKN period. Methods: Social network analysis (SNA) techniques were used to describe the structure of inter-professional knowledge exchange on the SKN system. Results: Results revealed that three of the five SKN moderators played a strong “collective brokerage” role in facilitating inter-professional knowledge exchange related to EHR MedRec, to enable learning and practice change. Together, they played complementary roles in reinforcing best-practice assertions, providing IT system education, and synthesizing collective learning moments, to enable “champions for change” to emerge from among SKN users. Conclusion: Results provide insight into the structure of effective knowledge-sharing networks for enabling inter-professional learning and practice change in health care organizations.

Background: In an effort to reduce medication discrepancies during transitions of care and improve accuracy of the patient's medication list, AU Health conducted a study to identify a comprehensive set of issues related to electronic health record (EHR) medication reconciliation (MedRec) from the perspective of practitioners directly involved in the EHR MedRec process. Methods: An exploratory mixed-method design was used. The 2-round study included 15 individual interviews, followed by a survey of 200 practitioners (ie, physicians, nurses, and pharmacists) based in the outpatient and inpatient medicine service at AU Health. Results: Thematic analysis of interview data identified 55 issue items related to EHR MedRec under 9 issue categories. The survey sought practitioners' importance rating of all issue items identified from interviews. A total of 127 (63%) survey responses were received. Factor analysis served to validate the following 6 of the 9 issue categories, all of which were rated “important” or higher (on average), by over 70% of all respondents: (1) care coordination (CCI); (2) patient education (PEI); (3) ownership and accountability (OAI); (4) processes-of-care (PCI); (5) IT-related (ITRI); and (6) workforce training (WTI). Significance testing of importance rating by professional affiliation revealed no statistically significant differences for CCI and PEI, and some statistically significant differences for OAI, PCI, ITRI, and WTI. Conclusion: There were 2 key gleanings from the issues related to EHR MedRec unearthed by this study: (1) there was an absence of shared understanding among practitioners, of the value of EHR MedRec in promoting patient safety, which contributed to workarounds, and suboptimal use of the EHR MedRec system; and (2) there was a sociotechnical dimension to many of the issues, creating an added layer of complexity. These gleanings, in turn, provide insights into best practices for managing both (1) clinical transitions of care in the EHR MedRec process and (2) sociotechnical challenges encountered in EHR MedRec implementation.

Background: Similar to issues faced in health systems across the USA, AU Health faced a scenario of low physician engagement in and limited use of its Electronic Health Record (EHR) Medication Reconciliation (MedRec) technology, which translated to high rates of medication discrepancies and low accuracy of the patient’s active medication list, during transitions of care. In fall 2016, a 2-year research grant was secured to pilot a Social Knowledge Networking (SKN) system on “EHR MedRec” to enable AU Health to progress from “limited use” of EHR MedRec technology to “meaningful use.” Purpose: The aims of this study were to 1) examine dynamics of interprofessional knowledge exchange and learning related to EHR MedRec on the SKN system and 2) explore associations between “SKN Use” and “Meaningful Use (MU) of EHR MedRec,” with the latter being assessed in terms of adherence to best practices in EHR MedRec. Methods: Over a 1-year period, 50 SKN Users (practitioners from inpatient and outpatient medicine settings), participated in discussing issues related to EHR MedRec, moderated by five SKN Moderators (senior administrators). Qualitative analysis was used to understand dynamics of interprofessional knowledge exchange and descriptive analysis was used to examine trends in two measures of MU of EHR MedRec, identified for the study. Results: Interprofessional knowledge exchanges related to EHR MedRec on the SKN system, progressed from “problem statements” to “problem-solving statements” to “IT system education” to “best-practice assertions” to “culture change assertions” to “collective learning (aha) moments” to lay a foundation for practice change. These interprofessional learning dynamics were associated with distinct improvement trends in both measures of MU of EHR MedRec technology. Conclusion: Results suggest that an SKN system could be a valuable tool in enabling MU of EHR MedRec technology. The study helps identify strategies for the creation of “learning health systems,” to enable successful change implementation in healthcare organizations.

How do conciliatory and coercive counterinsurgency tactics affect militant group violence against civilians? Scholars of civil war increasingly seek to understand intentional civilian targeting, often referred to as terrorism. Extant research emphasizes group weakness, or general state attributes such as regime type. We focus on terrorism as violent communication and as a response to government actions. State tactics toward groups, carrots and sticks, should be important for explaining insurgent terror. We test the argument using new data on terrorism by insurgent groups, with many time-varying variables, covering 1998 through 2012. Results suggest government coercion against a group is associated with subsequent terrorism by that group. However, this is only the case for larger insurgent groups, which raises questions about the notion of terrorism as a weapon of the weak. Carrots are often negatively related to group terrorism. Other factors associated with insurgent terrorism include holding territory, ethnic motivation, and social service provision.

This study explores how policy funding context—defined as whether funding for a social service policy domain is discretionary or mandated—affects network structures in social service domains. We present comparative findings from two social service policy networks which differ with respect to funding context: A 47-actor adult basic education policy network that is funded discretionarily and a 40-actor mental health policy network where spending is mandated. Both are located in a US state we pseudonymed “Newstatia.” Using an exponential random graph model, we found that policy funding contexts affect how the locus of resource dependence interacts with the nature of client groups to determine the array of interest organizations engaged in the networks, which leads to differentials in network structure across these domains. We suggest that policy funding contexts are before resource dependence and client factors when explaining network structure. This opens space for reconsideration of the causal claims between policy funding contexts, resource dependence, advocacy mobilization, and network structures.

This article offers an overview of the conceptual, substantive, and practical issues surrounding “big data” to provide one perspective on how the field of public affairs can successfully cope with the big data revolution. Big data in public affairs refers to a combination of administrative data collected through traditional means and large‐scale data sets created by sensors, computer networks, or individuals as they use the Internet. In public affairs, new opportunities for real‐time insights into behavioral patterns are emerging but are bound by safeguards limiting government reach through the restriction of the collection and analysis of these data. To address both the opportunities and challenges of this emerging phenomenon, the authors first review the evolving canon of big data articles across related fields. Second, they derive a working definition of big data in public affairs. Third, they review the methodological and analytic challenges of using big data in public affairs scholarship and practice. The article concludes with implications for public affairs.

Despite the federal policy impetus towards EHR Medication Reconciliation, hospital adherence has lagged for one chief reason; low physician engagement, which in part stems from lack of professional consensus about which physician is responsible for managing a patient’s medication list, and the value of medication reconciliation as a clinical tool for improving quality of care. The Technology-in-Practice (TIP) framework emphasizes the role of human agency (individual action) in enacting structures of technology use or “technologies-in-practice.” Applying the TIP framework to the EHR Medication Reconciliation context helps frame the problem as one of low physician engagement in performing EHR Medication Reconciliation, translating to limited-use-EHR-in-practice. Concurrently, the problem suggests a hierarchical network structure, reflecting limited communication among hospital administrators and physicians in regard to the value of EHR Medication Reconciliation in improving patient safety. Integrating the TIP literature with the more recent knowledge-in-Practice (KIP) literature suggests that EHR-in-practice could be transformed from “limited use” to “meaningful use” through the use of Social Knowledge Networking (SKN) Technology to create new social network structures, and enable engagement, learning, and practice change. Correspondingly, the aims of this conceptual paper are to: 1) Review the literature on technology use to understand how technologies-in-practice may be transformed from “limited use” to “meaningful use”; 2) Review the organizational change implementation literature to understand how changes in technology use could be successfully implemented and sustained; 3) Apply lessons learned from the literature reviews to identify strategies for the meaningful use and successful implementation of EHR Medication Reconciliation technology.

Background: The problem of interest in this study is the challenge of consistent implementation of evidence-based infection prevention practices at the unit level, a challenge broadly characterized as “change implementation failure.” The theoretical literature suggests that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Our study sought to both validate the theoretical literature and address this gap. Purpose: Correspondingly, this study posed two research questions. (1) What is the impact of periodic “top-down” communications on practice change at the unit level? (2) What are the “unit-level” communication dynamics enabling practice changes? Whereas this article focuses on addressing the first question, the second question has been addressed in an earlier Health Care Management Review article (Rangachari et al., 2013). Methods: A prospective study was conducted in two intensive care units at an academic health center. Both units had low baseline adherence to central line bundle (CLB) and higher-than-expected catheter-related bloodstream infections (CRBSIs). Periodic top-down communication interventions were conducted over 52 weeks to promote CLB adherence in both units. Simultaneously, the study examined (a) unit-level communication dynamics related to CLB through weekly “communication logs,” completed by unit physicians, nurses, and managers, and (b) unit outcomes, that is, CLB adherence and CRBSI rates. Findings: Both units showed increased adherence to CLB and significant, sustained declines in CRBSIs. Results showed that the interventions cumulatively had a significant negative (desired) impact on “catheter days,” that is, central catheter use. Practice Implications: Results help validate the theoretical literature and identify evidence-based management strategies for practice change at the unit level. They suggest that periodic top-down communications have the potential to modify interprofessional knowledge exchanges and enable practice change at the unit level, leading to significantly improved outcomes and reduced costs.