Diffusion, dissemination, and implementation: who should do what?

The concepts of diffusion, dissemination, and implementation are distinguished as progressively more active steps in the process of flowing valid and reliable research information into clinical practice. Using a staged model of behavior change, diffusion is seen as a precursor for dissemination activities, which in turn "predispose" physicians to consider change in their practices. Local implementation activities capitalize on this by "enabling" and subsequently "reinforcing" the desired behavior change. Different skills are needed for each activity. Biomedical journals, with some improvements, are identified as diffusion agents. Collaboration between academics and medical organizations is best suited to the dissemination stage. Local agents, empowered by resources, are best equipped for implementation activities.