1. DIFFUSION OF INNOVATION BEYOND THE TIPPING POINT:
The Case of the Regional Cancer Program Formulary Software
i-Society 2007
Merrillville, Indiana, USA
Michelle Goulbourne
Goulbourne Research and Consulting

2. Overview
 Describe the development and deployment of the Regional
Cancer Program Formulary Software (RECAP-FS).
 Summarize results of an interim survey and web statistics.
 Discuss the impact of each the following variables on the
rate of RECAP-FS adoption: (i) characteristics of the
innovation, (ii) the number of people involved in the
innovation decision, (iii) communication network structure
(iv) cultural context and (v) promotion efforts.
 Assess the importance of key ‘agents of change’ in taking
RECAP-FS beyond the tipping point to the level of cultural
change.
 Share lessons learned.

3. What is a Formulary?
 In Ontario, oncology formularies contain the systemic
therapy regimens approved for use for cancer patients.
 Regimens are based on published Cancer Care Ontario
Clinical Practice Guidelines (Formulary) and
institutionally approved treatments that are supported
by evidence (Non-formulary).
 The formulary when compiled usually takes the form of a
printed handbook.
 Despite best efforts once printed, these paper
formularies are soon out of date.
 The process of keeping the regimen details up to date is
a labour intensive process involving almost all clinical
pharmacist s.

4. Collaborative Formulary Maintenance
Dynamic reciprocal relationship
BR
CN SK
GI 11 DSTs SA Pharmacy
GU DST Chairs and ME Formulary and
Coordinators Therapeutics
GY Committee
LU
HN HE
CCO Guidelines

5. The Formulary Updating Process
Disease Site Team Based Model
Previous Formulary
Pharmacist 1 Pharmacist 2 Pharmacist 3 Pharmacist 4 Pharmacist 5
BR LU SK GY GI Other
Formulary and Therapeutics Committee
RECAP Formulary

6. Quality Gap
In Oncology pharmacy services, a quality gaps is said to have existed
because pharmacy services did not have the tools they need to:
1. Translate guidelines and clinical processes into regimens in an efficient
way (5 pharmacists involved in the updating process), and
2. Disseminate this information to staff, patients, families and other
stakeholders in a timely, cost effective way.
When quality gaps exist time is spent searching, checking, re-doing and/or
waiting.
These gaps in quality prevent us from; 1) enhancing the quality of
evidence and its use, (2) providing appropriate patient centered care, (3)
improving patient health status and outcomes, and (4)ensuring health
system sustainability and equity.
Quality gaps prevent us from creating value.

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

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

9. Why Innovate?
Why create the Regional Cancer Program Formulary Software?

10. Why Create RECAP-FS?
 Automate the process of editing, updating, exporting,
archiving and printing chemotherapy regimen
information.
 Add efficiency and cost effectiveness to the process of
disseminating regimen information in a timely manner.
 Enhance oncology community access to the latest
regimen information.
 Enhance patient care. (e.g. Booking clerks will have a up-
to-date resource to check nursing times  enhance
patient/work flow.)

11. Creating Value
For our customers as well as ourselves.

12. Value
“…should occur in the prevention, diagnosis, and treatment of
individual health conditions. It is at this level that true value is
created – or destroyed – disease by disease and patient by patient.
It is here where huge differences in cost and quality persist. And it
is here where competition would drive improvements in efficiency
and effectiveness, reduce errors and spark innovation.”
Porter and Olmsted Teisberg, 2004

13. Creating Value in Operational Terms
 Infrastructure needs to be in place that will allow us to take full
advantage of the potential of information, evidence and ideas in the
health care system.
 Need information management and technological systems in place that
will facilitate improvements in our ability manage the potential benefits
of health care technologies.
“…give health care providers access to the latest and best information on
new treatments or drugs, improve the quality and safety of care within the
health care system, and most importantly, empower patients to maintain
their own health.”
Commission on the Future of Healthcare, 2002

14. Strategic Drivers
Systems Perspective

15. Electronic Formulary to Enhance Quality
The Regional Cancer Program Formulary Percentage of Stage 1 and 2 Lung Cancer Patients Treated with
Software (RECAP-FS) is just one example Systemic Therapy in Accordance to Evidence
Made Available by CCO, Mid-2004**
of a project that seeks to help close this 100% 100%
particular quality gap in oncology. 100%
86%
95%
84%
91%
80%
System Drivers 60% 50%
40%
 Increase EBCPG use in Regimen Creation 20%
 Increase guideline adherence 0%
All centres Centre A Centre B Centre C Centre D Centre E Centre F
 Manage Costs Cancer Centres
Annual Expenditures and Number of Approved Drugs for the New
Local Level Goals Drug Funding Program 2000-2006*
Millions
$140 $133
1. Facilitate the provision of the best $120
available evidence based clinical care $100
$83
$80
$63
2. Enhanced patient status and outcomes $60
$42
$52
$59
$40
3. Contribute toward health system $20
14 16 16 18 18
sustainability $0
14
FY00/01 FY01/02 FY02/03 FY03/04 FY04/05 FY05/06
Year

16. Creating RECAP-FS
Patient Centric Approach

17. Patient Centric Model
Medical Care Process Factors
BR Patient Factors determine placement within
These process factors are a disease site based treatment framework
the major care steps that are CN HN where disease management is based on
needed to facilitate desired
DST stage. For example, in the Breast disease
medical outcomes. site group assessment decisions are made
for surgery, adjuvant radiotherapy, adjuvant
GI Disease Stage LU systemic therapy, etc.
GU Formulary Regimens MY Medical Care
Processes Factors are
documented in detailed
GY Detailed Care Paths SA paths.
Outcomes
HE Standardized Care Efficient Resource Utilization SK Analyses are
facilitated as
patient medical
Enhanced Patient Enhanced Quality of Enhanced Patient factors and
process factors
Safety Patient Care Outcomes are
documented.

18. Project Schedule
Phase I
Phase II
-April 03 project starts Phase III
-March 04 Test Survey
-1st Beta arrived July 03
- Aug 03 to Feb 04
-May 04 Regimen Review
- Dec 04-Jan05 Training
sessions
Phase IV
-Completed database update. - May 05-Aug 05 Beta - Nov 05 Launch
Database population
Testing Handbook, Software
and Icons
Apr 2003 – Mar 2004 - Dec 2004 - Nov 2005 –
Feb 2004 Dec 2004 Aug 2005 Dec 2005

19. Beta Testing
Building Capacity, Developing an Oncology Community
More than 40 staff from HHS and our community oncology
locations participated in the software testing process.
Beta testing served many purposes:
1. It engaged clinical and non-clinical staff at all levels in
the software creation process.
2. Provided the mechanism through which post-go-live
clinical champions were developed.
3. Increased staff knowledge about technology and
practical computer skills.

20. Tester Comments
Tester comment on the design, utility and functional specifications of
RECAP-FS® prior to its formal deployment directly contributed to the
success of this initiative. A few comments from beta tester evaluations
are below:
“Well laid out and functional.”
“I learned more about computers in the past hour than I have in the past
few years…”
“Not only will I be able to access up-to-date info faster, so will physicians.”
“Information will be accessible on the computer, where I do most of my
work.”

21. Introducing RECAP-FS
 A Quick Tour

22. RECAP-FS Main Menu
RECAP-FS® is used to create regimens for chemotherapy or combined modality
treatments. Produce a preformatted formulary for publication with the click of a button.
Generate dynamic reports containing a few or all of the variables in the database.

23. Cancer Regimen Information

24. CCO Guideline RECAP-FS Generated
Formulary

25. e-Health Desktop Icons
 The Regional Cancer Program e-Health Desktop Icons Software installs
three oncology information tools on the users computer desktop.
 Once installed, this software gives users immediate access to an always
up to date e-Book Formulary, over 160 Medication Information Sheets
(MIS) and over 200 Systemic Treatment Record summaries (STR).

26. Closing the Quality Gap With RECAP-FS
 The RECAP-FS project was completed in the fall of 2005.
 The software stores over 200 active formulary, non-formulary and
clinical trial regimens in its database.
 1000 handbook sized copies of the Formulary were printed and
distributed to staff across the Cancer Centre, Hamilton Health
sciences and community oncology satellite locations.
 This project suggests that technological innovations such as RECAP-
FS® can facilitate the development of positive and sustainable
changes in the culture and practice of health professionals.

27. Web Statistics
2006-2007 Pharm acy Services Web Statistics
1800
1600
1400
1200
Visits
1000
800
600
400
200
0
Systemic Treatment Record Medication Information e-Book Formulary RECAP-FS
Web Page
Mar-06 Apr-06 May-06 Jun-06 Jul-07 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07
2 click access to information 3 or more clicks to access information
Changes at the cultural level, that see staff regularly access and use formulary
resources, have a positive impact on patient safety and the quality of patient care.

28. Summary
 Using RECAP-FS® to generate online treatment information such as
the Regional Cancer Program e-Book Formulary and other free
online treatment information has allowed the Cancer Centre to share
evidence based best practices with patients, students, and clinical
staff within the global oncology community.
 Since its formal implementation in the fall of 2005 more than 600
users across Hamilton Health Sciences and the community oncology
affiliates have access to the latest oncology information via RECAP-
FS® and the RECAP e-Health Desktop Icons Software.
 Transitioning from novelty to sustained changes in day-to-day
clinical practice is an important task. Usability has been an
important factor contributing to the use of some of the tools to
access information.
 Each month over two thousand hits are registered on the RECAP website pages
and 90% of hits are linked to the pages that are accessed via the two-click
informational icons.

29. Tipping Point
The Tipping Point is that magic moment when an idea,
trend or social behavior crosses a threshold, tips, and
spreads like wildfire.
Gladwell, 2000

30. Change Agents->
Leading us Beyond the Tipping Point
The Clinical Champions
Administrative Change Agents

31. Online Survey
Evaluations completed one year after implementation suggest that
the Regional Cancer Program Formulary Software (RECAP-FS®) and
the RECAP Desktop Icons Software both play important roles in:
1. Helping pharmacy services attain their goal to disseminate best
practices in a way that helps to ensure the equitable and consistent
provision of high quality cancer care.
2. Providing information in a timely way so that healthcare teams can
work more effectively towards enhancing patient safety and
outcomes.

32. User Evaluations
- 1 Year after Implementation
 Despite the promotion of electronic health information 52%
of respondents indicated that they preferred the printed
handbook formulary.
 46% of respondents reported that they consulted the printed
formulary every day.
 81% of respondents received email updates announcing new
regimens were online.
 46% reported reviewing the regimens online and 36% printed
or saved the regimen file.
 64% reported that the RECAP-FS tools have had a positive
impact on the way they perform their work.

33. Beyond the Tipping Point
 The Regional Cancer Program Formulary Software (RECAP-FS®)
project sheds light on factors that impact on a tools rate of adoption
and sustained clinical use over time.
- Early staff involvement in the project and, the development of lead staff across sites
is critical in developing tools that meets and exceeds staff practice needs.
 The transition of an electronic tool from novelty to sustained changes
in day-to-day clinical practice is an important goal.
- Usability is an important facilitator in this process. During the first year of
implementation over two thousand hits were registered on the RECAP website
pages each month.
- 90% of the web hits were to pages that are accessed via the two click informational
icons.
 This project suggests that technological innovations such as RECAP-
FS® can facilitate the development of positive and sustainable
changes in the culture and practice of health professionals.
 Changes at the cultural level, that see staff regularly access and use
formulary resources, have a positive impact on patient safety and the
quality of patient care.

34. Key Learnings
1. Staff capacity building is needed for system change.
2. Develop clinical leaders during the course of the project
to enhance the likelihood of successful multi-site
software implementation.
3. Regional e-Health initiatives can have a positive region-
wide as well as a global impact. This potential needs to
be considered and incorporated into project goals.

35. Thank You

36. References
 Commission on the Future of Health Care (2002). Building on Values: The
Future of Health Care in Canada. Ottawa: Government of Canada.
 Gladwell, M. (2000). The Tipping Point. New York, Time Warner Book Group.
 Rogers E. (2003). Diffusion of Innovation, Fifth Ed., New York, The Free Press.
 Porter, M. E. and E. Olmsted Teisberg (2004). Redefining Competition in
Health Care. Harvard Business Review.