By Hannah K. Knudsen, Ph.D.
The Addiction Technology Transfer Center (ATTC) Network Technology Transfer (TT) Workgroup is to be commended for a cogent synthesis of core concepts from the ever-growing literature on technology transfer. This clearly written document offers definitions that should create a common language to facilitate discussions among diverse stakeholders about how technology transfer is a process rather than a discrete event.
While the literature on technology transfer, diffusion of innovations, and implementation science is expanding rapidly, the definitions of these core concepts highlight how much additional research is needed beyond multi-site clinical trials on the effectiveness of treatment interventions. The TT Workgroup describes “translation” as the stage where training packages and resources related to the intervention are made ready for “dissemination,” or the stage where awareness of intervention is promoted. The intersection of translation and dissemination is perhaps one of the areas in technology transfer where we need to know more.
Research is needed about whether the training packages developed for effective interventions are themselves effective in raising awareness and building knowledge. In addition, broader questions need to be addressed about the optimal strategies for dissemination:
What are the best modes for disseminating information about new interventions, particularly given the needs of adult learners?
What types of “messages” in these training packages are most persuasive to clinicians?
Are statistics and scientific evidence more persuasive than the narrative stories of individuals who have been helped by the intervention, or would dissemination packages be more effective if they combined these two types of messages?
To what extent can new social media be utilized to increase dissemination?
And at the same time, how can dissemination be accomplished for the programs that are at-risk of being “left behind” due to minimal access to computer resources, limited networking with other providers, and a lack of financial resources to support travel to face-to-face training events?
Given the growing number of evidence-based practices, is there a risk that dissemination efforts will start to become “white noise” that fails to get the attention of providers?
As the ATTC Technology Transfer Workgroup rightly notes, adoption is a process of decision-making about whether an intervention is going to be used. The decision-making aspect of technology transfer is actually an understudied topic. While researchers have made progress on identifying the types of programs that are more likely to adopt an evidence-based practice, less is known about how decisions get made:
For example, for an administrator considering adoption of buprenorphine, what are the key factors that that he or she considers?
How much weight do they give to the potential increase in client retention versus the costs associated with contracting with a physician?
How much more effective does buprenorphine need to be than the current standard of care to be attractive to a given treatment program?
Are they willing to increase efforts to attract more patients with private insurance who therefore have the means to pay for this treatment?
What role do opinion-leaders among the clinical staff and the board of directors have on this decision-making process?
Complicating matters even further is the fact that adoption decisions for psychosocial interventions fundamentally require that each individual clinician make the decision to try adding this intervention to their clinical practice. Some key questions for research include:
To what extent are the clinicians who adopt EBPs the ones who are already the “cream of the crop” (e.g., high performers with such strong skills that the clinical performance gains will actually be modest) or clinicians who realize that they need new strategies to increase client retention and treatment completion because too many of their patients are leaving treatment early?
Can clinicians really be persuaded to adopt EBPs that diverge from their current treatment model?
Implementation, or the incorporation of an innovation in routine practice, continues to be a stage of the technology transfer process that needs more research. To return to the example of medication-assisted treatment, we have a paper that is in press in Journal of Addiction Medicine that describes the average percentage of clients with opioid dependence or alcohol use disorders who are receiving the FDA-approved medications for these conditions (Knudsen et al., in press). In the subset of programs that had adopted MAT, the average rates of MAT implementation were 34% for opioid-dependent patients and 24% for clients with alcohol use disorders. The next question then is, “Why this gap in implementation?” When it comes to implementation of psychosocial EBPs, we need to understand whether clinicians incorporate an EBP with all their patients or treat it as one option from a menu of EBPs based on their patients’ characteristics. (And if the latter is the case, how do they decide which EBP for which patient?) Finally, under what conditions will clinicians discontinue using an EBP?
The ATTC Technology Transfer Workgroup has distilled the core concepts of technology transfer into an easy-to-understand resource that should be valued by a range of stakeholders. Hopefully, this document will stimulate additional ideas for research in the emerging field of implementation science. When I read their article, it certainly generated a wide variety of ideas for new directions for my own work, and I hope others have a similar experience.
Hannah K. Knudsen
University of Kentucky