By ATTC Technology Transfer Workgroup
The ATTC Network Technology Transfer workgroup is grateful to the editorial board of The Bridge for their thoughtful feedback about the ATTC Network Model of Technology Transfer in the Innovation Process that we put forth in the feature article of this issue. Respectfully, we offer the following response.
A Model with a Shaky Foundation?
Dr. Brigham argues that the field needs a clear definition of “evidence-based practice.” We concur that a more cohesive scientific vetting process for evidence-based substance abuse treatment practices would be helpful. While there are systems, such as the APA guidelines, the Cochrane Collaborative, and the NREPP rating system, there is no set of agreed-upon standards or an agency analogous to the FDA to enforce such standards. We appreciate the suggestion that we should have included more specific language in the description of the Development phase of the ATTC model to clarify this stated need. We do not, however, feel it was within the purview of the Workgroup to establish the “reasonable scientific threshold” Dr. Brigham discusses. The ATTC Model was designed to be a broad conceptual model, rather than defining or promoting a specific method for operating in any stage of the model. Accordingly, just as we do not delineate a specific method for evaluating an innovation in the Development stage, we also do not offer a “correct” model for integrating an innovation into routine practice in the Implementation stage. The Workgroup’s goal was to provide a framework for discussing the continuum of the diffusion of innovations in a mutually understandable way using like terms. As such, we applaud Dr. Brigham’s call for more clear thinking and definitions of basic terms like evaluation, evidence, safety and effectiveness thresholds.
Suggested Refinements for a Model of Technology Transfer
One of Dr. Martino’s comments is that the inclusion of Development in the ATTC Model may be confusing. He argues that an innovation must first be developed before it is diffused into practice; thus, including Development in the model obscures the distinction between these two concepts. He also notes that well-established models of development already exist (i.e., Onken, Blaine, & Battjes, 1997; Rounsaville, Carroll, & Onken, 2001). We appreciate the delineation of the difference between development and diffusion. In fact, the ATTC Model clearly shows that diffusion begins after development. Somewhat similar to our response to Dr. Brigham, while Onken and colleagues’ model of development is well accepted (and prominently mentioned in our forthcoming article in the Journal of Substance Abuse Treatment), our intention is to provide a broad framework for the life of an innovation, not to delineate the specifics within each stage. Furthermore, because of the importance of bi-directionality in the innovation process (implementers affect how innovations are developed, and vice versa), we firmly believe that development should be included in the model.
Dr. Martino also highlights the need to prepare programs prior to implementing a new treatment practice, “an ounce of preparation during the dissemination stage by technology transfer specialists could be worth a pound of implementation later in the process.” While the Workgroup concurs that individual and organizational preparation plays a key role in the success of implementation efforts, we suggest that such work is most appropriate during Adoption. An EBP package should include a list of resources needed for implementation, and this should be highlighted during Dissemination as providers learn about new treatments. However, Adoption is the stage in which a provider really reviews such information in reference to actual use of the practice. Some of the preparatory work highlighted by Dr. Martino, such as developing a consensus about the potential value of a new treatment, should occur during Adoption. Overall, the ATTC Network is keenly aware of the importance of organizational change as evidenced by the principles and steps outlined in one of the Network’s seminal publications, The Change Book (ATTC Network, 2004).
Dr. Martino also argues for increased evaluation of whether technology transfer efforts, such as those employed by the ATTC Network, are successful. We also would like to see increased evaluation of ATTC technology transfer efforts although our principal funding stream does not currently allot resources for such work. We note that the Substance Abuse and Mental Health Services Administration recently completed an external evaluation of the ATTC Network, and we are hopeful that when the findings are released more measures of our success will be evidenced.
New Models Mean New Questions: How the ATTC Technology Transfer Model Suggests New Directions for Research
Dr. Knudsen sees the ATTC Technology Transfer Model as a catalyst for articulating new research questions. In considering practical implications for our work, one of the specific hopes of the Workgroup has been that the model would do just that – spark creative ideas for studying the technology transfer process. We are excited by the multitude of potential research questions Dr. Knudsen puts forth based on our field-driven model of technology transfer. We would especially like to underscore two of her lines of inquiry. One is the intersection of translation and dissemination. Dr. Knudsen discusses the need to study whether training packages created in the Translation stage are effective and whether there are optimal strategies for dissemination. There is relatively little research, except for several seminal studies (e.g., Miller et al., 2004; Sholomskas et al., 2005), on effectiveness of training in changing clinical skills. In part, this is because often the outcomes of such studies have been measured as whether clinicians use the new skills (which is really implementation), rather than their competence in using the skills. The second line of inquiry which we feel is particularly important is relation to Adoption. Dr. Knudsen suggests that the field needs to more closely investigate how organizations approach and make decisions in the “Adoption” stage. Again, some work has been done in this area, including Panzano and Roth’s (2008) study of a risk-based decision-making framework and Roman, Knudsen, and colleagues’ (e.g., Knudsen, Ducharme, & Roman, 2007; Knudsen, Roman, & Oser, 2010; Roman, Abraham, Rothrauff, & Knudsen, 2010) examinations of organizational factors. We agree with Dr. Knudsen that the model encourages research across the diffusion continuum, and think that these two areas are particularly relevant to the field’s continued ability to accelerate the uptake of evidence-based interventions in practice.
The Need for More Attention to the Requirements for Implementation
In his response, Mr. Boyle presents a case for why it is more difficult to adopt and implement evidence-based substance abuse treatments than other innovations, such as utilizing a new kind of corn seed or prescribing a different type of medicine. The Workgroup concurs with Mr. Boyle that implementation of complex clinical practices is easier said than done. While changing a business practice or a non-clinical practice, such as providing a more comfortable waiting room, may be relatively easy to target, understand and complete in a short period of time, changing clinical practice is often an intricate process, necessitating a well-coordinated effort at individual, organizational, and systemic levels. Moreover, merely changing clinical practice is not the end goal; rather the goal is to change practice in a particular way that conforms carefully with the way the practice was originally researched. EBPs generally do not work as well as demonstrated in the research if they are not implemented with fidelity (Durlak & DuPre, 2008; Gearing, 2011; McHugo et al., 1999). Adding the need for high fidelity change creates yet another layer of complexity in the process of implementing evidence-based clinical treatment practices since there exists a variety of distinct contextual factors that exist in “real-world” treatment settings. While full implementation across the spectrum of substance abuse treatment services may be illusive, we heartily agree with Mr. Boyle’s argument that promoting such practices has allowed for a “cultural sea change,” which, he implies, has benefitted the provision of treatment services.
The Role of the State Authority in Technology Transfer
Dr. McCarty addresses the issue of further operationalizing the ATTC Technology Transfer Model for specific stakeholders, such as the state authority—Single State Authority (SSA). He notes that the Advancing Recovery project (funded by the Robert Wood Johnson Foundation) focused on state authority-provider agency partnerships to spur implementation of evidence-based practices in substance abuse treatment. This is a such a key partnership and Advancing Recovery provided a nice model of how these two groups can work together in concert toward a shared vision rather than a more antagonistic model of states mandating changes without working with agencies on the implementation process. Clearly a number of stakeholders have roles to play in the complex process of innovation. As a first step toward operationalization, the Workgroup has developed a Matrix companion to the Model, (available at www.ATTCnetwork.org/technologytransfer). The Matrix outlines roles and actions that states and systems (including SSAs), researchers, ATTCs, organizations, clinical supervisors, and clinicians can take at each stage of the innovation process to accelerate technology transfer.
Standardizing Communication in Technology Transfer: A Biblical Parallel?
Dr. Roman provides the Tower of Babel parable, suggesting that it may be too early in the life of implementation science to put forward standardized definitions and models. His reasons, briefly, are that the field does not have a typology of innovations, it does not have a definition of evidence-based practice, and that we may not yet fully understand what implementation is (Dr. Roman notes, is it ‘just a lot of adoption’). The Workgroup’s intent in advancing the conceptual model is to provide a framework for the major components or stages in the life of an innovation, so that all of the stakeholders can speak a similar enough language to be understood, not to necessarily be definitively correct. As noted several times in this response, the intent is not to prescribe within each stage the specific processes by which each stage works. We recognize the state of the science and the practice in the field is not there yet (nor may ever be). However, it is the Workgroup’s opinion that progress and innovation have been hampered by people using the same terms to mean different things. A framework, not a completed tower, and common definitions of key terms can assist in communicating about the technology transfer process to stakeholders across multiple vantage points. That is one of the lessons that the ATTC Network, with our national range and somewhat difficult acronym, has learned. We agree that it is too early to define the specifics within each stage of innovation, but disagree that the type of broad conceptual model that we advance is premature.