Objective To evaluate the policy making process, implementation by NHS organisations, and patients' and carers' experiences of efforts to introduce an internet accessible personal electronic health record (HealthSpace) in a public sector healthcare system. Design Mixed method, multilevel case study. Setting English National Health Service; the basic HealthSpace technology (available throughout England) and the advanced version (available in a few localities where this option had been introduced) were considered.

Saharan dust storms have often been observed from space, but the full impact on the Earth's radiation balance has been difficult to assess, due to limited observations from the surface. We present the first simultaneous observations from space and from a comprehensive new mobile facility in Niamey, Niger, of a major dust storm in March 2006. The results indicate major perturbations to the radiation balance both at the top of the atmosphere and at the surface. Combining the satellite and surface data, we also estimate the impact on the radiation balance of the atmosphere itself. Using independent data from the mobile facility, we derive the optical properties of the dust and input these and other information into two radiation models to simulate the radiative fluxes. We show that the radiation models underestimate the observed absorption of solar radiation in the dusty atmosphere.

Objective To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care. Design Multi-site, mixed method case study applying utilisation focused evaluation. Setting Four early adopter sites for the SCR in Englandthree in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR's material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters' concerns (especially about workload and the ethicality of sharing "confidential" information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension for change, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme).Conclusion Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the microlevel by the material properties of the technology, individuals' attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care. INT...

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Trisha Greenhalgh and Jill Russell discuss the relative merits of “scientific” and “social practice” approaches to evaluation and argue that eHealth evaluation is in need of a paradigm shift.