Integrating systems thinking and implementation science in biomedical informatics research.

Objective: Implementing biomedical informatics (BMI) tools and applications into clinical and other settings remains a significant challenge. Unintended consequences remain common post-implementation. This paper addresses the above issue by integrating systems thinking and implementation science approaches to support health information technology (HIT) implementation. Materials and Methods: We reviewed systems thinking and implementation science approaches. We then formally integrated systems thinking and implementation science to better understand system interactions to address implementation issues at the patient, organizational, and broader health system levels. Results: We developed a four-stage systems-based approach and a set of five pragmatic principles to support systems-based implementation research. Discussion: Our four-stage approach helps understand the dynamic interactions across system concepts during HIT implementation. Our principles advocate viewing HIT implementation as a "system of systems" rather than as individual entities, using appropriate terminology to describe a system, and using lifecycles and iterative upstream approaches to guide implementation research. Conclusion: We must draw on the existing body of evidence from the systems thinking and implementation science literature. Our findings build on the strong foundation of systems thinking and implementation science research and practice. We also provide guidance on how to incorporate this knowledge systematically and practically.