Implementing Evidence-Based Practice in Community Clinics: A Process Evaluation of Barriers, Adaptation, and Workflow Integration in the United States

Background Evidence-based practices (EBPs) are problem solving-approach practices in the clinical setting that incorporates the best available research evidence which could include the best practice or expertise while looking out for the patient's values and preferences. They are mandated in the US community clinics based on federal policy and Medicaid contracting requirements. Although these mandates were created to level the playing field for both standardized quality care and implementation within routine care workflows, however, this has not been the case. Existing studies infer that EBP implementation failure is driven by the misalignment amongst organizational, technological and workflow not the clinician acceptance of usage. Objectives This study used the process evaluation techniques to assess the Implementation of Evidence-based Practice in Community Clinic in the United States community clinics with the aim of identifying major barriers, adaptation patterns, and workflow integration dynamics. Methods A process evaluation was conducted on twenty-eight (28) literature using an analytic approach informed by implementation science. The EBP investigated was a standardized clinical screening tool needed to be regulated during routine care encounters with patients and documented in the structured electronic health record (EHR) system to meet the Medicaid quality reporting requirements. Data sources were empirical studies from peer-reviewed papers that contained federal and state policy documents, EHR documentation specifications, workflow artefacts, and implementation guidance relevant to community clinic operations. Data analysis was done through structured thematic synthesis and mapping workflow with the end goal of establishing implementation frameworks and how they can be translated into real-world experience. Findings: Implementation barriers were mostly impeded by the lack of flexibility in the EHR system, the burden that comes from documentation, time pressure constraints and audit-driven compliance. Clinicians never resisted the use of EBPs, rather they engaged in informal adaptations such as shifting tasks, developing a workaround within the workflow, alteration of task sequencing, and documented later to make sure patient routine care continues. This resulted in partial fidelity, hidden compliance, and divergence between reported and enacted practice. Conclusions This evaluation reveals that the implementation outcomes in community clinics are controlled mostly by the compatibility of workflow and the context of the clinical environment as opposed to the clinician's attitude towards EBPs. Hence, it is important to design EBPs and implementation approach that can work in the real-world clinical workflows to attain sustainability in the community clinic setting. MSC Code: 00A06