Blog Center for Dissemination & Implementation

What we don’t know about dissemination and implementation science

Written by Enola Proctor, PhD, Shanti K. Khinduka Distinguished Professor at the Brown School

In one decade, implementation science has experienced an “explosion” of progress in both quality and quantity, according to Dr. David Chambers, Deputy Director for Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute. The Washington University team of has been at the forefront of leading the field, through several key accomplishments. WashU faculty helped lead the field authored the field’s first text, developed and reviewed conceptual models, pioneered research training programs and D&I cores in CTSA programs, and developed taxonomies of implementation strategies and outcomes, and authored reporting guidelines. Yet the field has far to go—we need to find answers to some important questions that today we can’t answer.

What are the new frontiers for dissemination and implementation science? Here are five questions we can’t answer now, but I believe we can answer and must answer in the next five years.

Question one: How early in the process of intervention development should we consider implementation?

At WashU, the D&I team is working with a new gut microbiome initiative in the earliest phases of discovery research to anticipate implementation issues, to shorten the time between intervention development and eventual adoption in real-world care. Similarly, the NIH-supported IGNITE program seeks to pave the way for implementation of genomic medicine discoveries.

It is hard to anticipate how we will implement something that hasn’t yet been discovered, or proven effective. Yet delaying implementation considerations only prolongs the research translation timeline—now estimated to be 17 years. Surely we can shorten that process by considering implementation earlier in the discovery process. Our teams are working to discover how we “design for dissemination/implementation” as new diagnosis, prevention, and treatment programs are developed.

Question two: All implementation is local: True or false?

Former Speaker of the US House of Representatives Tip O’Neill persuaded us that “all politics are local.” But what about implementation?

Implementation science focuses on generalizability, through the use of theoretically driven rigorous research design. No implementation can succeed without adaptation to local contexts, engagement of local stakeholders, and tailoring of implementation strategies. So how do we balance the local with the generalizable? Answering this question will require capturing rich detail of context, comparative analyses of implementation efforts across different contexts, and prospective trials that test same implementation strategies across different contexts, settings, and circumstances. Addressing this issue will also help us map the mutual value-added of implementation science and quality improvement.

Question three: Which implementation outcomes most, and when, and to whom?

Our teams have often observed that when considering the adoption of new guidelines, interventions, technologies, and policies, different stakeholders raise different concerns. CEOs often worry about cost. One CEO succinctly asked, “How much will this change cost, and how much havoc will it wreak in my organization?”

Implementing something new requires change, and change is always hard. Providers often worry about the goodness of evidence. Researchers often worry about fidelity to protocols that were tested in the lab. How do we manage these multiple concerns, and how does the change process best begin? How can we shape the change process to address these real, but sometimes different, concerns?

Question four: Which implementation strategies are most effective, where, for what outcomes?

This question logically follows question three. We need to find the dissemination and implementation strategies that make evidence more credible to providers, and to patients and their families (think vaccine debate). We need to learn the true costs of organizational change. We need to discover strategies that help providers and organizations sustain a new protocol, once it is initially adopted. These are tough questions, but answering them is critical to learning how to implement new discoveries in real-world settings.

Question five: What’s the value added of quality implementation?

This may be the toughest, but certainly the most critical of the five “frontier” questions I’ve posed. How much can successful implementation contribute to making our health systems more efficient? To reducing health disparities? To making health care safer? Answering this question will establish the “return on investment”—the business case for implementation science, help establish research priorities, and perhaps demonstrate the value of funding for implementation science.

Washington University’s dissemination and implementation researchers have helped build the field. Now they are propelling it forward by answering tough but important questions, and reducing what we don’t know. Join us in this quest.