Dissertations / Theses on the topic 'EHR'

A need for improvement in nursing education regarding inpatient workflows and informatics skills was identified at this project site. Upon hire, nurses were required to complete a 4-hour basic class on the electronic health record (EHR) system, but this class did not include inpatient-nursing workflows needed to provide and facilitate care for patients. This project addressed the lack of EHR education on inpatient nursing workflows. The focus of this staff education project was an education class on inpatient nursing workflow provided to a nurse residency class. Sources of evidence were obtained through a literature search and pretest/post test data analysis. The literature used to support the project included articles on best practices for EHR education for nursing. The pretest and post test design was used to determine if there was an increase in EHR knowledge after the education. Benner's novice-to- expert model served as the framework. The mean total proficiency scores on inpatient nursing workflows in the EHR improved from pretesting to post testing, (6.8 to 7.8, p = 0.048). The study findings showed improvement in participants' average proficiency, knowledge, and clinical skills in the EHR. This project findings demonstrated the need for an inpatient nursing informatics workflow class for all nursing staff, and the findings supported an increase in education to facilitate workflow and care safety. This project promotes positive social change by improving curricula, raising awareness of how technology affects clinical care and practice, and encouraging continuous quality improvement through informatics education.

Many countries (especially developing countries) are plagued with critical healthcare issues such as chronic, infectious and pandemic diseases, a lack of basic healthcare programmes and facilities and a shortage of skilled healthcare workers. E-Health (healthcare based on the Internet technologies) promises to overcome some problems related to the reach of healthcare in remote communities. Electronic Health Record (EHR) (consisting of all diagnostic information related to a patient) forms the core of any E-Health system. Hence the success of an E-Health system is very much dependent on the success of the EHR systems. Although interest in automating the health record is generally high, the literature informs us that they do not always succeed in terms of adoption rate and/or acceptance, even in developed countries. The success of the adoption tends to be low for resource constrained (e.g. insufficient E-Health infrastructure) developing countries. As part of the effort to enhance EHR acceptance, readiness assessment for the innovation becomes an essential requirement for the successful implementation and use of EHR (and hence E-Health). Based on a thorough literature review, several research gaps have been identified. In order to address these gaps, this thesis (based on design science research methodology) presents E-Health Readiness Assessment Methodology (EHRAM). It involves a new E-Health Readiness Assessment Framework (EHRAF), an assessment process and several techniques for analysing the assessment data to arrive at a readiness score. The EHRAF (Model) integrates the components from healthcare providers?? and organisational perspectives of existing E-Health readiness evaluation frameworks. The process of EHRAM (Method) starts with the development of a set of hierarchical evaluation criteria based on EHRAF. This leads to the questionnaire development for data collection. The data is analysed in EHRAM using a number of statistical and data mining techniques. The instantiation part of the design science research involves an automated tool for the implementation of EHRAM and its application through a case study in a developing country.

Ifølge denne avhandling var norske allmennleger godt fornøyd med bruk av elektronisk pasientjournal (EPJ) sammenlignet med papirjournaler, men tilgjengeligheten av informasjonen i store elektroniske journaler var ikke tilfredsstillende. Det ble funnet relativt effektiv tidsbruk av EPJ under konsultasjonene. Bruk av EPJ forstyrret ikke konsultasjonene ifølge legene eller pasientene som deltok i undersøkelsene. Det ble funnet at allmennlegene får god støtte fra EPJ til å utføre 21 av 24 oppgitte kliniske oppgaver. Det var ikke utviklet funksjonalitet i systemene til å støtte de resterende tre oppgavene. 19 av de 21 oppgavene ble svært mye brukt. Systemenes generelle brukertilfredshet og suksess ble rapportert som høy eller svært høy. Det var ingen forskjeller mellom systemene med hensyn til evne til å understøtte kliniske oppgaver, men et av systemene ble rapportert å ha flere maskin- og programvarefeil og noe lavere brukertilfredshet og suksess. Resultatene ble sammenlignet med en tilsvarende undersøkelse blant sykehuslegers og deres EPJ systemer. Allmennlegene var mer fornøyde med EPJ enn deres sykehuskolleger med hensyn på brukertilfredshet, evne til å understøtte kliniske oppgaver og effekt på arbeidskvalitet. Selv om allmennlegene var fornøyde, ønsket de forbedringer på flere områder i EPJ. De savnet støtte til medisinske beslutninger som kunne tilpasses den enkelte pasient. De ønsket at all helsefaglig kommunikasjon skulle foregå elektronisk, og de ønsket elektronisk støtte for å kunne konsultere spesialister ved behov. De ønsket også at deres EPJ skulle kunne kommunisere med pasientene og deres eventuelle framtidige egenjournal. En metode for utvikling av funksjonelle kravspesifikasjoner til EPJ ble prøvd ut. De deltagende allmennpraktikere valgte ut 67 krav fra EPJ standarden, og formulerte 197 nye funksjonelle krav for å kunne oppnå vellykket elektronisk støtte til helsefaglig samarbeid i helsevesenet. Bakgrunnen for avhandlingen var et ønske om å undersøke hvordan allmennpraktikere i Norge vurderte bruken av elektroniske journalsystemer, sammenligne disse vurderingene med sykehuslegers vurderinger av sine systemer, og undersøke hvordan allmennlegene ønsket sine elektroniske journalsystemer utviklet videre. Det ble gjennomført fire studier i denne avhandlingen, og det ble brukt både kvantitative og kvalitative metoder. De kvantitative data ble innsamlet gjennom en nasjonal spørreundersøkelse. De kvalitative data ble innsamlet ved fokus gruppe intervjuer, ved observasjoner av allmennleger i klinisk arbeid og ved dokumentanalyse og metoder fra aksjonsforskning. En av studiene var kvantitativ og benyttet kun data samlet inn fra spørreskjemaundersøkelsen. I to av studiene var metodene triangulerte, og det ble benyttet data fra spørreskjema, intervjuer og observasjoner. Den siste studien var kvalitativ og samlet inn og analyserte data fra dokumentanalyser og metoder fra aksjonsforskning.

Thesis: S.M. in Management Studies, Massachusetts Institute of Technology, Sloan School of Management, 2016.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 68-75).
Since the 1970s, the healthcare industry has been moving from paper-based documents towards computer information systems in an effort to increase timely access to quality information, with the ultimate objective of wide dissemination and adoption of Electronic Health Records (EHRs). EHRs are electronic collections of patient health information that are recorded by physicians, nurses and patients themselves, before being approved by physicians and shared across diverse settings. EHR implementation can improve care quality and efficiency and physician productivity and reduce healthcare costs. However, implementation often proves to be difficult. This paper reviews several common issues associated with EHR adoption including negative impacts on quality of care, physicians' productivity, patients' safety and organizations' financials from high maintenance and implementation costs. It then summarizes critical success factors found in the literature. It eventually examines two cases studies of Enterprise Resource Planning (ERP) implementation in the automotive and food and beverage industries and leverages ERP implementation best practices to develop a practical framework for successful HER adoption. Hopefully, it will be useful for future EHR adoption projects in the U.S. and other regions of the world.
by Sacha Barry.
S.M. in Management Studies

Magister Commercii - MCom
This study aimed to understand the readiness and perceptions of Electronic Health Record (EHR) adoption among dentists in the public service of the Western Cape. A qualitative study design was chosen due to a lack of understanding of the phenomena. Additionally, the research sought to identify the factors that would potentially influence readiness and perceptions in order to identify how these factors could potentially influence EHR adoption among dentists.

Providing an interoperability infrastructure for Electronic Healthcare Records (EHRs) is on the agenda of many national and regional eHealth initiatives. Two important integration profiles have been specified for this purpose: the "
IHE Cross-enterprise Document Sharing (XDS)"
and the "
IHE Cross Community Access (XCA)"
. XDS describes how to share EHRs in a community of healthcare enterprises and XCA describes how EHRs are shared across communities. However, currently no solution addresses some of the important challenges of cross community exchange environments. The first challenge is scalability. If every community joining the network needs to connect to every other community, this solution will not scale. Furthermore, each community may use a different coding vocabulary for the same metadata attribute in which case the target community cannot interpret the query involving such an attribute. Another important challenge is that each community has a different patient identifier domain. Querying for the patient identifiers in another community using patient demographic data may create patient privacy concerns. Yet another challenge in cross community EHR access is the EHR interoperability since the communities may be using different EHR content standards.

Uganda is accentuating a lot of efforts to strengthen its healthcare services and provide National Electronic Health Record System. One of the core components of Electronic Health Record System is Statistical Information System. The Statistical Information System locates in the application logic in the technical architecture of the whole project. Exsiting tool, DHIS 2 is evaluated and found not proper to be used as the project's Statistical Information System. Based on the discussions above, the system is divided into 3 parts: Static Statistics, Dynamic Statistics and HMIS Reports. The static part provides powerful search for statistics. The dynamic part utilizes a flash chart, where users can see the move of statistics like watching a movie. The HMIS part is the place where the traditioncal HMIS reports can be generated

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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES
Network Design Problems (NDPs) are present in many areas, such as electric power distribution, communication networks, vehicle routing, phylogenetic trees among others. Many NDPs are classified as NP-Hard problems. Among the techniques used to solve them, we highlight the Evolutionary Algorithms (EA). These algorithms simulate the natural evolution of the species. However, in its standard form EAs have limitations to solve large scale NDPs, or with very specific characteristics. To solve these problems, many researchers have studied specific forms of representation of NDPs. Among these stands we show Node-Depth-Degre Encoding (NDDE). This representation produces only feasible solutions, regardless of the network characteristics. NDDE has two mutation operators Preserve Ancestor Operator (PAO) and Ancestor Change Operator (CAO) and the recombination operator EHR (Evolutionary History Recombination Operator) that uses historical applications of mutation, and was applied to NDPs more than one tree and had good results. Thus, this work proposes adapt EHR for NDPs classics represented by a single tree. In addition, two evolutionary algorithms are developed: the AE-RNPG, which uses only NDDE, with mutation operators. And the AE-EHR, which makes use of mutation operators and recombination operator EHR to the One Max Tree Problem. The results showed that the AE-EHR obtained better solutions than the EA-RNPG for most instances analyzed.
Problemas de Projeto de Redes (PPRs) estão presentes em diversas áreas, tais como reconfiguração de sistemas de distribuição de energia elétrica, projetos de redes de comunicação, roteamento de veículos, reconstrução de árvores filogenéticas entre outros. Vários PPRs pertencem à classe de problemas NP-Difíceis. Dentre as técnicas utilizadas para resolvê-los, destacam-se os Algoritmos Evolutivos (AE), cujo processo de resolução de um problema simula a evolução natural das espécies. Entretanto, os AEs em sua forma padrão também possuem limitações quanto a PPRs de larga escala, ou com características muito específicas. Para solucionar esses problemas, diversas pesquisas têm estudado formas específicas de estruturas de dados dos PPRs. Dentre essas destaca-se a representação Nó-Profundidade-Grau (RNPG). Essa representação produz apenas soluções factíveis, independente da característica da rede. A RNPG possui dois operadores de mutação Preserve Ancestor Operator (PAO) e Change Ancestor Operator (CAO) e o operador de recombinação EHR (Evolutionary History Recombination Operator), que utiliza o histórico de aplicações dos operadores de mutação, o qual tem sido aplicado a PPRs com mais de uma árvore com bons resultados. Este trabalho propõem a adequação do EHR para PPRs clássicos de uma única árvore. Além disso, são desenvolvidos dois algoritmos evolutivos: o AE-RNPG, que utiliza a RNPG somente com os operadores de mutação; e o AE-EHR, que faz uso tanto dos operadores de mutação quanto do operador de recombinação EHR para o problema da Árvore máxima. Os resultados obtidos mostram que o AE-EHR obtém melhores soluções do que o AE-RNPG para a maioria das instâncias analisadas.

Information technology (IT) has been rapidly integrated into the healthcare industry, including nursing, and has the ability to reduce errors, cut cost, and enhance patient care. However, approximately 45% of the current nurse workforce lacks adequate training in computer skills, which may hinder the adoption of health-related IT in the workplace. Characteristics of Rogers's diffusion of innovation (relative advantage, compatibility, complexity, trialability, and observability) guided this project. This project was conducted to address the problem of IT adoption on a local level and was designed to assess whether simulation training on a generic electronic health record (EHR) system would improve the knowledge, skill, and attitude of nurses with little or no experience with EHR. A convenience sample of nurses (n = 13) unfamiliar with EHR was obtained by posting flyers in long-term care or home health agencies. The nurses completed the P.A.T.C.H. assessment scale v. 3 (2011) before and after participating in the one-time simulation training on EHR. Scores on the P.A.T.C.H. were calculated according to the established scoring system and revealed a positive increase nurses' attitude and self-efficacy toward the EHR system. Posttest scores yielded an increase ranging from 0.5 to 5 points from pretest scores, with an average pretest score of 54.23 on a scale of 0-100. The results of this project are consistent with the literature and current research and illustrate the importance of addressing the need for interactive training. This project contributes to social change in practice by enhancing the awareness of EHR in nurses who are new users of IT and promoting the adoption of technology in healthcare.

Our modern health care system requires technology that can deal with multidisciplinary and complex processes, operations, and situations. The EHR, by far, is one of the greatest health information technology innovations that satisfy these requirements because of its efficiency and the effectiveness of its features. This study sought to develop an in-depth understanding of how underserved patients' perspectives about their health and illness, can contribute to greater use of the EHR. It also sought to improve their health outcomes and maintain sustainable change in the lives of the underserved. A quantitative non-experimental design study was conducted over a 6-week period outside of three different internal medicine clinics, one in the Northwestern and the two others in the Southeastern regions of Washington, DC. Surveys were distributed directly to patients coming out of these health clinics, and participants sent their responses via mail. Data collection included 215 surveys out of 560, but, only 155 fit the overall study categories. A strong level of significance in the relationships between clinical outcome measures and the EHR was identified at a 95% confidence interval. There were considerable health determinants that demonstrated the essence of patients' perspectives and the need for its incorporation into health outcomes measures for the underserved populations. The study also identified sets of environmental health predictors which acted as facilitators and contributors to a holistic health management model designed to contribute to the needs of the underserved communities. The holistic health model and the individual care plan model derived from the study are applicable at the level of the underserved population. It can help achieve sustainable health outcomes that will save lives and promote better health.

This degree project deals with electronic health record (EHR). The report is divided into two main sections; literature study on electronic health record and an EHR system implementation. In the literature study section, EHR background, development history and service condition are introduced. The paper focuses on the sharing of medical information in different users, data safety and privacy. The adjunctions of computer science, technologies are used to solve the medical informatics’ problems. In the implementation section, based on the study of the current EHR systems, the design and implement of a shared EHR system are presented, which can be accessed by different doctors and patients. Access control function and cryptography protections are included in this system. The system test and evaluation are also given.

A significant amount of evidence existed in support of the positive effect on the quality of healthcare that resulted from transitioning to electronic health information systems, equally compelling evidence suggests that the development process for electronic health information systems falls short of achieving its potential. The objective of this research was to assess the existing HIT standards and health information management (HIM) principles to determine if they are robust enough to inform the development of national and international interoperability standards. The research question asked; How do HIT standards and HIM principles and practices influence the quality of EHR performance? This study’s goal was to maintain focus on the collaborative challenges revealed by the lack of understanding and shared vision that commonly exists between HIM professionals, HIT developers, and HIT vendors that obstruct synergy and enfolding of health information standards-based capabilities and HIM practice (business) standards. The complex electronic health record (EHR) universe proved well suited for testing by a combination of complexity science and the unified theory of acceptance and use of technology (UTAUT) information management theories. Through analysis of research literature and qualitative interviews, the research identified nine factors defined into drivers and barriers that influenced the actions of healthcare organizations; leadership, patient focus, planning, communication, alignment with lifecycle models people, processes, dynamics, training and user input, change management standard adoption, and recognition of the power of technology. Analysis of the data obtained from exploratory qualitative interviews of health information technology professionals selected from a professional healthcare management organization supported conclusions that leadership, collaboration, planning, and training limiters, have a direct impact on EHR system success or failure.

In healthcare, vulnerable populations that are using medications with a narrow therapeutic index and wide interpatient PK/PD (pharmacokinetic/pharmacodynamic modelling) variability are increasing. As such, variable dosage regimens may result in severe therapeutic failures or adverse drug reactions (ADR). Improved monitoring of patient response to medication and personalization of treatment is therefore warranted. Precision dosing aims to individualize drug regimens for each patient based on independent factors obtained from a patient’s clinical records. Personalization of dosing increases the accuracy and efficiency of medication delivery. This can be achieved through utilizing the wide range of Electronic Health Records (EHR) contain the patients’ medical history, diagnoses, laboratory test results, demographics, treatment plans, biomarker data; information that can be exploited to generate a patient-specific treatment regimen. For example, Fast Healthcare Interoperability Resources (FHIR) is an existing healthcare standard that provides a framework on which semantic exchange of meaningful clinical information can be developed such as using an ontology as a decision support tool to achieve precision medicine. The purpose of this thesis is to make an investigation of the feasibility of interoperability in EHR and propose an ontology framework for precision dosing using currently existing health standards. The methodology involved carrying out of semi-structured interviews from professionals in relevant areas of expertise and document analysis of already existent literature, a precision dosing ontology framework is developed. Results show key tenants for an ontology framework and drugs and their covariates. The thesis therefore advances to investigate how data requirements in EHR systems, IT platforms, implementation, and integration of Model Imposed Precision Dosing (MIPD) and recommendations have been evaluated to cater to interoperability. With modern healthcare striving for personalized healthcare, precision medicine would offer an improved therapeutic experience for a patient.

Thesis: Ph. D., Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, 2015.
This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.
Cataloged from student-submitted PDF version of thesis.
Includes bibliographical references (pages 123-126).
Clinical predictive modeling has the potential to revolutionize healthcare by allowing caregivers to allocate resources effectively, resulting not only in lower costs but also in better patient outcomes. Electronic health records (EHR), which contain large volumes of detailed patient information, are a great resource for learning accurate predictive models using advanced machine learning and data mining techniques. In this thesis we develop techniques that can exploit available patient information to learn clinical predictive models while tackling the challenges inherent in the data. We present our work in the context of predicting disease progression in chronic diseases. We present a novel feature representation that exploits hierarchical relationships between high cardinality categorical variables to tackle the challenge of high dimensionality. Our approach reduces feature dimensionality while maintaining variable-specific predictive information to yield more accurate predictive models than methods that ignore the hierarchy. For predicting incident heart failure, we show that by leveraging hierarchy in the diagnosis and procedure codes, we can improve the area under the receiver operating characteristic curve from 0.65 to 0.70 and the F-score from 0.37 to 0.40. Using simulation, we further analyzed the properties of the data that affect the amount of improvement obtained by leveraging hierarchy. We also present a method to exploit temporal information in longitudinal EHR data. Our multitask-based machine learning approach captures time varying effects of a predictor. Our results show that by exploiting temporal information, our approach can improve risk stratification of patients with compromised kidney function over a model that only use the most recent patient information. Specifically, our proposed approach is able to boost sensitivity from 37.5% to 55.1% (for a precision of ~~ 50%) when identifying patients at high risk of rapid progression of renal dysfunction.
by Anima Singh.
Ph. D.

Emergency Department (ED) providers and staff experience challenges with using electronic health record (EHR) software to document and communicate about patient care. These difficulties are often caused by inadequate training in the use of the organization's EHR system. Challenges with EHR use have been linked to increased ED patient wait times, which impacts patient safety by delaying care and increasing the potential for medication errors. Providing education that addresses EHR software; EHR usability; and collaboration among staff, providers, and EHR system managers has been shown to reduce ED wait times and decrease the risk of medication errors. The purpose of this project was to evaluate a new ED Safety EHR educational module and to identify provider and staff difficulties when operating ED EHR software. The goal of this project was to provide relevant education to ED providers and staff, which could minimize the impact of EHR use on patient safety in the emergency setting. Relational coordination theory and Kolcaba's theory of comfort framed this project. Five local ED staff and providers considered experts in EHR software utilization were chosen to review and validate the content of the educational module using a ten question, 4-point Likert scale survey. All five experts agreed that the content of the ED Safety EHR educational module was easy to read, comprehensible, and relevant. One noted area of weakness involved the technical language used in the educational module. Participants requested language simplification prior to implementation. This project promotes social change by addressing the need for ED EHR education as a strategy to reduce ED patient wait times and minimize the risk of medication errors in the emergency setting.

Thesis (S.M. in Engineering and Management)--Massachusetts Institute of Technology, Engineering Systems Division, System Design and Management Program, 2012.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 90-94).
Radiology is a medical specialty that employs imaging to diagnose and treat disease. It has long been an advance user of technology to capture, store, share, and use images electronically. In 2009, President Obama signed into law a measure, the HITECH Act (part of the stimulus package), that incentivizes healthcare providers to use electronic health records (EHR) in care delivery to improve quality, efficiency, safety, and reduce cost. The meaningful use (MU) program's Stage 1 requirements (part of HITECH Act) did not include imaging requirements, leading to confusion among radiologists and other specialties with regard to what MU offers to and requires of them. This thesis attempts to clarify the contribution radiology can make to MU by understanding radiology as a system, including its surrounding issues and its drivers, using Stage 1 MU requirements, data from qualitative research, and results from analysis. It answers the following question: Should Radiologists be considered part of the care team, leveraging EHR for meaningful use and hence eligible for incentive payments? It does so via the following methods: a) Discussing in detail current issues surrounding radiology systems from quality, safety, efficiency, and cost perspectives; b) Discussing MU in the context of radiology and reviewing what is missing in it for radiologists; c) Providing deeper systems analysis of current behaviors and why they have this form at this time; and d) Explaining how MU objectives can help to overcome many current issues and ultimately help to improve health outcomes. Specific changes to MU criteria to achieve these benefits are recommended. This thesis employs systems concepts and tools including system architecture and system dynamics for research and analysis to understand the system and derive hypotheses. A system dynamics model is used to analyze current drivers in imaging and to clarify the impact MU can have on these drivers. Thesis conclusions are supported by the analysis performed using the model as well as information gathered through industry interviews, online articles, academic and industry journals, and blogs.
by Palani Perumal.
S.M.in Engineering and Management

The Electronic Health Record (EHR) has the potential to promote understanding or awareness of healthcare knowledge among patients and healthcare providers to facilitate collaboration between various key stakeholders to improve the quality of healthcare. The technology is also expected to provide global health communities with benefits, from improved health outcomes, reduced medical errors, and a reduction in healthcare expenditure. These benefits will not be realised unless the key stakeholders and consumers of the technology are willing to accept, adopt, and use the EHR. The purpose of this study is to identify crucial factors influencing clinicians’ adoption of the EHR in South Africa’s healthcare system by expanding the Unified Theory of Acceptance and Use of Technology (UTAUT) model to include the additional constructs Resistance to Change and Attitude Towards Organisational Change. A cross-sectional online questionnaire was used to gather data from 168 clinicians employed at various private and public healthcare facilities across South Africa. Performance expectancy and facilitating conditions were found to have a statistically significant positive impact on clinicians’ behavioural intention, whereas effort expectancy and social influence had no similar result. Resistance to change had a statistically significant negative influence on behavioural intention, and a negative attitude towards organisational change positively influenced resistance to change. The findings of this study can be used by government bodies, the private sector and technology vendors to better understand clinicians’ perceptions of the EHR in order to guide policy and effect implementation strategies accordingly.
Mini Dissertation (MBA)--University of Pretoria, 2020.
Gordon Institute of Business Science (GIBS)
MBA
Unrestricted

This thesis examines the potential interface that exists between health information, specifically electronic health record (EHR) systems, and notifiable disease surveillance in Canada. It aims to highlight the benefits and barriers experienced by the current national notifiable disease surveillance strategy, as well as to highlight the successes and roadblocks to the successful implementation and adoption of EHR technologies in Canada. Qualitative methodologies, which include the 16 semi-structured interviews conducted with four key stakeholder groups, including public health experts, physicians, health administrators and academics that are concerned with EHR adoption and public health were used to obtain data. Data from interviews was analysed using grounded theory methodology and then verified using member checking and other data validation methods. Emergent themes from obtained data indicated that there is a large potential for the improvement of the current notifiable disease through the use of EHR technologies: however, the barriers currently faced by both the notifiable disease surveillance system and the state of implementation and adoption of EHR technologies prevent this from occurring. These barriers include political, financial, human, security/privacy, and technology barriers. Differences between stakeholder groups were explored, and potential solutions and insights into existing barriers were provided. The information gained from this study provides insight into the efficiency of the current infectious disease surveillance system and the progress of and need for the implementation of EHRs nationwide. In addition, the results of this study provide stakeholders with a deeper understanding of the barriers facing the use of EHR technologies for infectious disease surveillance and provide a starting place to address these issues. The results of this study can help to inform policy regarding public health surveillance and EHR implementation and adoption.

The  rapid  digitization  in  the  health  care  sector  leads  to  an  increaseof  data.  This  routine  collected  data  in  the  form  of  electronic  healthrecords (EHR) is not only used by medical professionals but also hasa  secondary  purpose:  health  care  research.  It  can  be  opportune  touse this EHR data for predictive modeling in order to support medi-cal professionals in their decisions. However, using routine collecteddata  (RCD)  often  comes  with  subtle  biases  that  might  risk  efficientlearning of predictive models. In this thesis the effects of RCD on theprediction performance are reviewed.In particular we thoroughly investigate and reason if the performanceof  particular  prediction  models  is  consistent  over  a  range  of  hand-crafted sub-populations within the data.Evidence  is  presented  that  the  overall  prediction  score  of  the  algo-rithms trained by EHR significantly differ for some groups of patientsin  the  data.  A  method  is  presented  to  give  more  insight  why  thesegroups of patients have different scores.

Durante las últimas décadas se ha extendido la implantación de sistemas de información en las organizaciones sanitarias, proporcionando un adecuado soporte a los principales procesos de las mismas. Sin embargo, a pesar de los avances producidos durante los últimos años en las tecnologías de la información y la comunicación, los sistemas actuales no son capaces de proporcionar un verdadero soporte a los profesionales sanitarios en su práctica diaria y sus actividades de investigación. Como consecuencia de la variedad de organizaciones sanitarias existentes y la heterogeneidad de los sistemas de información en uso, los sistemas actuales de Historia Clínica Electrónica no son capaces de mostrar a los profesionales sanitarios una visión conceptualmente consolidada del estado de salud de los pacientes. Los datos clínicos de los pacientes se encuentran fragmentados tanto entre diferentes sistemas de información como dentro de los mismos, de modo que los profesionales deben interpretar las relaciones entre los mismos así como inferir relaciones ausentes. En este escenario, la interoperabilidad semántica es considerada por la comunidad científica como un factor esencial para que los sistemas de HCE constituyan una ayuda para mejorar la calidad y seguridad de la atención a los pacientes, la salud pública, la investigación clínica y la gestión sanitaria. En esta tesis proponemos OntoEHR, una arquitectura conceptual para un nuevo sistema de HCE semánticamente interoperable, enfocado sobre el proceso clínico y dirigido por ontologías. Tanto los elementos conceptuales como estructurales del sistema son definidos explícitamente mediante ontologías OWL, conforme a un metamodelo declarativo que dirige el sistema. Los datos clínicos procedentes de diferentes fuentes son almacenados e integrados en un repositorio clínico, conforme con la norma CEN/ISO 13606, que es capaz de comunicar los datos clínicos mediante extractos CEN/ISO 13606. Por último, proponemos un modelo de Historia Clínica Orientada por Problemas, basada en la norma CEN/ISO 13940, para representar los datos clínicos de los pacientes, asegurando una continuidad asistencial segura y eficiente. Esta tesis no propone ningún sistema de HCE específico y completo, sino las bases para construir tales sistemas.
The deployment of information systems in healthcare facilities has become widespread in recent decades and the main processes at Healthcare facilities are generally well supported. However, in spite of great advances in information and communication technologies domain during last years, current systems fail to provide true support to healthcare professionals in their daily practice and research activities. As a consequence of the variety of organizations providing healthcare and the heterogeneity of information systems used, current Electronic Health Record systems are not capable to show to healthcare professionals a conceptually consolidated view of the patients’ health state. Patient’s health data are fragmented inside information systems and over different information systems, and the professional should interpret and infer lacking relationships among them. In this scenario, semantic interoperability is pointed out by scientific community as an essential factor in achieving benefits from EHR systems to improve the quality and safety of patient care, public health, clinical research, and health service management. In this thesis we propose OntoEHR, a conceptual architecture for a new semantically interoperable EHR system, focused on the clinical process and driven by ontologies. Conceptual and structural elements of the system are explicitly defined in OWL ontologies, conforming a declarative metamodel that drive all the system. Clinical data coming from different sources are stored and integrated in a clinical repository conforming to CEN/ISO 13606 standard, which is able to communicate clinical data using CEN/ISO 13606 extracts. Lastly, we propose a Problem Oriented Medical Record model, founded on CEN/ISO 13940 standard, to represents patients’ clinical data, assuring a safe and efficient continuity of care. This thesis do not propose a specific and complete EHR system, but the foundation to build such systems.

Introduction: Human biospecimens such as surgical tissue and blood are essential for some types of biomedical research because they contain genetic material (genes contained in living organisms). Because of their genetic content, biospecimens are able to add great value to fields of study such as genomics, molecular biology and biological chemistry. Increasing knowledge in these fields holds promise for improving healthcare for individual patients (precision medicine), as well as the broader healthcare community. These genetic materials obtained from patient donors are procured, stored and dispersed through a complex operation called biobanking. Biobanking systems are involved with two primary functions, 1) procure sufficient quantities of human biospecimens allowing researchers the materials required to answer scientific questions, and 2) capture relevant corresponding clinical and phenotypic information for eventual correlation with scientific results. This capture and manipulation of corresponding information (e.g. clinical, pathological, and environmental) are where the value of the biospecimens are maximized for research purposes. The complexity of biobanking requires informatics to integrate the biospecimen-related information with corresponding clinical and phenotypic data. In designing biobanking systems, informatics must be considered as they play a vital role in managing the samples and data in a timely fashion as well as reducing the costs associated with biobanking.

Background: Biobanks are resources that play a key role in the procurement, processing, storage and dispersal of human biospecimens. Collections of human tissue have been a common place in hospitals and specialist clinics since the nineteenth century when preservation techniques were introduced. Governance concerning these human biobanks has evolved and is set by institutional, regional, national and international policy. They can be public (e.g. non-profit, academic, governmental), private (e.g. for-profit or pharmaceutical industry) or public-private partnerships. Regardless of the governance level or specific research focus of the biobank, the next generation of biobanking resources will require interdisciplinary collaborations and integrated informatics approaches to accelerate the procurement and use of the research biospecimens.

Methods: A literature search was conducted to explore biobanking informatics configurations and architecture to determine the context and extent of the software applications utilized in current biobanking systems. There were a substantial number of publications describing informatics architecture and their export of data to a Virtual Data Warehouse or Centralized Research Data Repository. However, there was a lack of published literature specifically describing use of an enterprise-wide electronic health record (EHR) in the initial three upstream workflows (i.e. clinical, pathology and biobank) involved with most institutional biobanking systems. Patient data generated/utilized in these three workflows are manually double-entered into separate information applications as there is no direct data exchange/export between EHR and the Laboratory Information System (LIS) or the Biorepository Information Management System (BIMS) specifically to assist with biobank procurement. Therefore, an EHR integrated-access informatics model was designed that would maximize benefits created by the EHRs capabilities in the upstream workflows of an institutional biobanking system. The approach described in the thesis was designed and documented using a model driven UML tool and incorporates an EHR integrated-access approach along with inter-departmental workflow processes. Interoperability gaps were identified that could take advantage of institutional EHR software existing at most large academic healthcare institutions or teaching hospitals. This model synergistically integrates the EHR, LIS and BIMS to maximize information exchange during the upstream biospecimen procurement workflow. This informatics model for institutional biobanking is based on the premise that commercial software applications are already implemented at most large academic healthcare facilities and they can be utilized within their biobanking systems.

Conclusion: This EHR integrated-access model would enhance sharing of key research data between three software applications (EHR, LIS, BIMS) that are available at most large academic medical centers that perform research biobanking. The informatics model would promote data exchange between processes of three primary biobanking steps in the clinic, pathology department and biobank improving efficiency and increasing biospecimen procurement. Large healthcare facilities who have EHR, LIS and BIMS applications available could utilize this EHR integrated-access model as a first-step in improving their biobanking informatics workflow to increase high-quality biospecimen collections. New methodologies that improve the success of biobanks can eventually lead to institutional biobanking systems playing a major role in a path to personalized medicine.

Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

The hospitals and their healthcare providers need to optimize simultaneously three outcomes: healthcare costs, healthcare options offered to customers, and information utilization efficiency. The adoption of electronic healthcare record (EHR) technologies is a potential managerial mechanism for balancing these outcomes. EHR offers patient management and decision support capabilities that can ameliorate health delivery outcomes for patients, doctors, and hospitals through better-informed business and care decisions. The analysis of data collected in an EHR system may lower costs and improve health care delivery (or both). In sum, it could be argued that EHR is a source of competitive advantage. Despite this prima facie appeal, many hospitals remain reluctant to adopt and implement EHR due to lack of insights into return on investment, unavailability of tested systems and data entry obstacles. To address this gap between the potential of EHR system and lack of its adoption, the purpose of this research is to investigate the role of EHR as a resource of competitive advantage for hospital. Essay 1, titled "Implementation and Adoption of EHR: A Conceptual Model based on Resource Advantage Theory", describes the antecedents and consequences of EHR adoption and implementation. Essay 2, titled "Exploring the Relationship Between Electronic Healthcare Record Adoption and Quality of Care", delves deeper into the operational performance of a hospital. This essay focuses on the impact of EHR on different aspects of patient care and thereby on the financial performance of the hospital. Essay 3, titled "The Effect of Resources on a Hospital's Financial Performance: The Moderating Role of Electronic Health Records Implementation and Adoption", is an empirical inquiry into the key factors that may influence hospitals' financial performance. These include organizational factors (such as, number of nurses and beds) and environmental factors (such as, location and received donations). Further, this essay explores the interaction effects between EHR and these factors. In summary, this research provides a conceptualization and an empirical investigation of EHR adoption and implementation and its impact on hospitals' operational and financial performance, an area receiving widespread attention from health care organizations, patient rights activists, public policy makers and the media. Future research can take two paths. First, further research should address questions related to the integration of EHR with other production and inventory management systems, and the prospective benefits attained from system integration. Second research is needed to investigate how parallel information transfer across multiple stakeholders may concurrently preserve Health Insurance Portability and Accountability Act, reduce health care delivery costs and optimize service quality.

Electronic medical records (EMRs) or electronic health records have been in use for years in hospitals around the world as a time-saving system for patient record keeping. Despite its widespread use, some physicians disagree with the assertion that EMRs save time. The purpose of this study was to explore whether any time saved with the use of the EMR system was actually devoted by doctors to patient-care and thereby to improved patient-care efficiency. The conceptual support for this study was predicated employing the task-technology fit theory. Task-technology theorists argue that information technology is likely to have a positive impact in individual performance and production timeliness if its capabilities match the task that the user must perform. The research questions addressed the use of an EMR system as a time-saving device, its impact on the quality of patient-care, and how it has influenced patients? access to healthcare in Nigeria. In this research, a comparative qualitative case study was conducted involving 2 hospitals in Nigeria, one using EMRs and another using paper-based manual entry. A purposeful sample of 12 patients and 12 physicians from each hospital was interviewed. Data were compiled and organized using Nvivo 10 software for content analysis. Categories and recurring themes were identified from the data. The findings revealed that reduced patients? registration processing time gave EMR-using doctors more time with their patients, resulting in better patient care. These experiences were in stark contrast to the experiences of doctors who used paper-based manual entry. This study supports positive social change by informing decision makers that time saved by implementing EMR keeping may encourage doctors to spend more time with their patients, thus improving the general quality of healthcare in Nigeria.

Health information technology (HIT), which includes electronic health record (EHR) systems and clinical data analytics, has become a major component of all health care delivery and care management. The adoption of HIT by physicians, hospitals, post-acute care organizations, pharmacies and other health care providers has been accepted as a necessary (and recently, a government required) step toward improved quality, care coordination and reduced costs: “Better coordination of care provides a path to improving communication, improving quality of care, and reducing unnecessary emergency room use and hospital readmissions. LTPAC providers play a critical role in achieving these goals” (HealthIT.gov, 2013). Though some of the impacts of evolving HIT and EHRs have been studied in acute care hospitals and physician office settings, a dearth of information exists about the deployment and effectiveness of HIT and EHRs in long-term and post-acute care facilities, places where they are becoming more essential. This dissertation examines how and to what extent health information technology and electronic health record implementation and use affects certain measurable outcomes in long term and post-acute care facilities. Monthly data were obtained for the period beginning January 1, 2016 through June 30, 2017, a total of 18 months. The level of EHR adoption was found to positively impact hospital readmission rates, employee engagement, complaint deficiencies, failed revisit surveys, staff overtime (partial EHR), staff turnover rate (full EHR) and United States Centers for Medicare and Medicaid Services (CMS) Five Star Quality score. The level of EHR adoption was found to negatively impact CMS Five Star Total score, staff retention rate (full EHR) and staff overtime (full EHR group higher than partial EHR).

Canada lags behind other countries in the development of electronic health records. If Canada develops a pan-Canadian electronic health record (EHR) system, the quality of patient care can improve. A review of the literature lists potential benefits of EHRs such as improvements in medical research, a reduction in emergency room and diagnostic test wait times. Such a system will make medical records readily available to health care providers which will help them make informed critical decisions. Regardless of the benefits of such a system, there are legal and ethical implications hindering its development and implementation. The federal and provincial governments are at odds as to who is in charge of health care. Canadians need to be consulted on its implementation, and their concerns regarding privacy legislation addressed. Canada Health Infoway has undergone initiatives to create an interoperable EHR system in Canada with audit trails, smart card technology, etc. The benefits of such a system are seen in an analysis of Alberta that has created its own provincial EHR system. Case studies of both Alberta and the United Kingdom's EHR systems should be used as a foundation to begin developing Canada's national system. If Canada addresses the concerns surrounding the implementation of a national EHR system through policies with sanctions to deal with the ethical implications of such a system (informed consent, unlawful access, etc), then studies have shown that Canadians will support a pan-Canadian EHR system initiative. Before addressing ethical dilemmas, the governments must assume responsibility of who will develop and maintain this system.
Le Canada accuse un retard important par rapport à d'autres pays dans le développement de dossiers de santé électroniques. Si le Canada développe un système de dossier de santé électronique pancanadien (DSE), la qualité des soins patients peut s'améliorer. Une revue de la littérature décrit les avantages potentiels des DSEs tels que des améliorations de la recherche médicale, une réduction au niveau des temps d'attente en salle d'urgence et des tests diagnostiques. Un tel système facilitera la disponibilité des dossiers médicaux pour les fournisseurs de soins médicaux et les aideront à prendre des décisions critiques éclairées. Indépendamment des avantages d'un tel système, des implications sur le point de vue légal et éthique empêchent son développement et sa mise en œuvre. Les gouvernements fédéraux et provinciaux sont en désaccord quant à qui la responsabilité des soins médicaux incombe. Les Canadiens doivent être consultés sur la mise en œuvre de ce système et leurs préoccupations quant à la législation sur la vie privée doivent être adressées. Inforoute Santé du Canada a entrepris des démarches afin de créer un système de DSEs interopérable au Canada avec des protocoles d'audit, la technologie de carte à puce, etc. Une analyse de l'Alberta, qui a créé son propre système de DSE provincial, a permis de voir les bénéfices d'un tel système. Les études de cas portant sur les systèmes de DSEs de l'Alberta et du Royaume-Uni devraient être utilisées comme fondement afin de débuter le développement d'un système national au Canada. Les études ont démontré que les Canadiens supporteront l'initiative d'un système de DSE pancanadien si le Canada adresse les préoccupations entourant la mise en œuvre de ce système national par des mesures avec sanction afin de répondre aux implications éthiques que ce dernier pose (le consentement éclairé, l'accès illégal, etc.). Avant d'adresser les dilemmes éthiques que pose ce système, les gouvernements doivent assumer la responsabilité de décider qui développera et maintiendra ce système.

In today’s world, information systems are increasingly necessary for organizations to continue to provide their services with quality. These systems have become increasingly heterogeneous and complex. Executing them in an integrated manner with other systems has become a prerequisite. Due to the existence of legacy systems with stored data that needs to be maintained, the integration between systems is impaired. This situation is aggravated when it comes to health information systems because there are specific laws that require that data need to kept for decades. One well-known health information system is the Electronic Health Record (EHR). The EHR system is the electronic record of the patient’s health consisting of information coming from di erent systems. These systems are often developed by di erent companies and use di erent technologies. With this in mind, the use of a Service-Oriented Architecture (SOA) becomes very useful, since it is a solution capable of integrating heterogeneous structures using specific standards such as web services. However, designing SOA-based systems is not a trivial task. A robust and well-defined architecture is crucial to the success of applications based on SOA paradigm. Therefore, this study aimed to present a software architecture for the development of an EHR system based on SOA considering interoperability between legacy systems. Thus, a set of research methods were applied. Initially, a literature review was conducted in order to find relevant papers that could help in the development of applications in healthcare. This review was bounded on the studies related to EHR systems. The review of these studies aimed to first build a base of knowledge about problems, di culties and challenges regarding the implementation of EHR systems. The analysis of the literature showed that there was a deficiency in precisely defining a specific architecture for the development of EHR systems.The architecture is used a case study in order to test the applicability of the same. The object of this study was the University Hospital of the Federal University of Sergipe where it was developed an EHR system prototype. The architecture proposed in this work was of fundamental importance to the development of the EHR system prototype. The proposed architecture has enabled communication between the EHR system prototype and applications that mimicked the Legacies systems. Among the limitations of the case study, that were not possible to be used to the real legacy systems to the achievement of architecture tests. Applications were created that simulated real systems. However, these simulations did not a ect the result of the study which showed how to satisfactorily creating a software architecture based on SOA for building an EHR system considering interoperability between legacy system.
No mundo atual, sistemas de informação são cada vez mais necessários para que organizações continuem prestando seus serviços com qualidade. Estes sistemas têm se tornado cada vez mais heterogêneos e complexos. Funcionar de maneira integrada com outros sistemas passou a ser um pré-requisito. Devido à existência de sistemas legados com dados armazenados que precisam ser mantidos, a integração entre sistemas fica prejudicada. Essa situação é agravada quando se trata de sistemas de informação em saúde pois existem legislações específicas que exigem que os dados sejam mantidos por décadas. Um sistema de informação em saúde bem conhecido é o Electronic Health Record (EHR). O sistema EHR é o registro eletrônico de saúde do paciente composto por informações vindas de diversos sistemas. Estes sistemas muitas vezes são desenvolvidos por empresas diferentes e utilizam tecnologias diferentes. Com isso em mente, o uso de uma Service-Oriented Architecture (SOA) se torna bastante útil, visto que é uma solução capaz de integrar estruturas heterogêneas utilizando padrões específicos como por exemplo web services. No entanto, projetar sistemas baseados em SOA não é uma tarefa trivial. Uma arquitetura robusta e bem definida é crucial para o sucesso de aplicações baseadas no paradigma SOA. Por essa razão, este trabalho teve como objetivo apresentar uma arquitetura de software para desenvolvimento de um sistema EHR baseado em SOA considerando a interoperabilidade entre sistemas legados. Para tanto, um conjunto de métodos de pesquisa foram aplicados. Inicialmente foi realizada uma revisão da literatura com o intuito de encontrar trabalhos relevantes que pudessem auxiliar no desenvolvimento de aplicações na área de saúde. Esta revisão foi delimitada a estudos relacionados aos sistemas EHR. A revisão destes estudos visou primeiramente construir uma base de conhecimento a respeito de problemas, dificuldades e desafios em relação a implementação de sistemas EHR. A análise da literatura mostrou que existia uma deficiência justamente na definição de uma arquitetura específica para o desenvolvimento de sistemas EHR. Assim, foi definida uma arquitetura de implementação e esta foi utilizada em um estudo de caso com o objetivo de testar a aplicabilidade da mesma. O objeto deste estudo foi o Hospital Universitário da Universidade Federal de Sergipe onde foi desenvolvido um protótipo de sistema EHR. A arquitetura proposta neste trabalho foi de fundamental importância para o desenvolvimento do protótipo de sistema EHR. A arquitetura proposta permitiu a comunicação entre o protótipo de sistema EHR e as aplicações que simularam os sistemas legados. Entre as limitações do estudo de caso, destaca-se a não utilização de sistemas legados reais para a realização dos testes da arquitetura. Foram criadas aplicações que simularam os sistemas reais. No entanto, estas simulações não interferiram no resultado do estudo que mostrou de maneira satisfatória a criação de uma arquitetura de software baseada em SOA para construção de um sistema EHR considerando a interoperabilidade entre sistema legados.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.
Case based instruction (CBI) in medical education is a well established alternative to lecture format in the training of first and second year medical students. There have been previous documented attempts to include technology in CBI that have received positive feedback from students. Electronic health records are now being mandated by 2014 and historically there have been many barriers to adoption including lack of EHR technical skills by physicians. As a result, biomedical informatics education is being integrated into medical school curriculum with hope that better understanding of medical applications will prepare future physicians to utilize them. There has been no documented evidence of successful utilization of a commercial grade EHR within CBI despite many potential benefits in doing so. Previous attempts at accomplishing this task have been discovered but multiple challenges were encountered in developing a suitable educational EHR and as a result the attempt was unsuccessful. The following is a design project with the aim of highlighting specific design requirements, as well as, a theoretical usage scenario of a commercial grade EHR in CBI. Outlined as well is experimental design for future evaluation of such a system. There will be many 4 technological challenges that will need to be overcome and numerous resource requirements to get such a project functional. Despite this, all aspects of such a system are technologically feasible. Completion of such a system could result in potential commercial benefit and provide a platform for further investigation of early EHR training effect on physician-EHR acclimation.

Magister Commercii - MCom
Information and communication technologies (ICT) have changed the way healthcare processes are being documented. This results in better quality and ethical vigilance to ensure a more accurate form of data recordkeeping (Stevenson, Nilsson, Petersson & Johansson, 2010). Health care in South Africa, is facing major issues relating to patient care, such as delays in patients receiving medical care. According to the national Department of Health, the improvement of public healthcare facilities is crucial (McIntyre & Ataguba, 2017). Information and communication technology (ICT) has the ability to significantly alter the status of healthcare services in the Western Cape, which can be achieved through the role of an electronic healthcare record (EHR).

Despite a Presidential Order in 2004 that launched national incentives for the use of health information technology, specifically the Electronic Health Record (EHR), adoption of the EHR has been slow. This study attempts to quantify factors associated with adoption of the EHR and Computerized Provider Order Entry (CPOE) by combining multiple organizational theories and empirical studies. The study is conducted in two phases. The primary phase of this study identifies and evaluates the effects of external environmental and internal organizational factors on healthcare organizations to adopt the EHR. From secondary data, twelve IVs (df=19) are chosen based on existing models and literature. Logistic regression is used to determine the association between the environmental factors and EHR adoption. The secondary phase of this study examines the adoption of five variations of CPOE using the same IVs from phase one. This EHR component of CPOE is chosen due to its promotion as a solution to help cross the quality chasm (IOM, 2001). Secondary data are analyzed and logistic regression is used to quantify the association between the factors of EHR adoption and CPOE adoption. Eleven of the twelve IVs are significant between the two phases (p<.1). This study uses data from 2009 because the HITECH Act was passed that year and significant government incentives were offered for those health care organizations (HCOs) that meet the qualifications of meaningful use. This study serves as a baseline for future studies, extends the work of other empirical studies, and fills a gap in the literature concerning factors associated with the adoption of the EHR and specific dimensions of CPOE. The Kruse Theory developed is strongly based in literature and reflects complexity commensurate with the health care industry.

Nowadays, the main concern for any service provider organization is to improve their services with reducing the time of service accompanying with increase in their efficiency and effectiveness. In healthcare systems, specially, these concerns are much more important where the information is the core material of providng services to patients. Electronic health record (EHR) systems are designed to address these concerns and using them is becoming more and more important for many countries. EHR systems provide many capabilities to hospitals with collecting, sharing and manipulating information in the digitals format. Moreover, actual EHR systems enable hospitals to share their patient information with any other hospital no matter of the first location of storing data. Incorporating a system with the main goal of making integrity between different organizations is not an easy task and many challenges and problems should be considered to make the system efficient for the organizations. Although many good attempts have been done in some developing countries such as Denmark and USA this issue is still a big challenge for many developing countries. In this research study, it is tried to review the situation of EHR systems in a developing country to extract the challenges and barriers for adopting it. At first, the researcher has a deep literature review on past works on EHR from different aspects. After extracting needed information, a case study will be run to better understanding of the real situation and make a comparison between the literature and real environment. The researcher selected Iran as a developing country to review its healthcare system and the degree of using computerized system in the organizations.
Program: Magisterutbildning i informatik

The Centers for Medicare and Medicaid Services issued over 144,000 payments totaling $7.1 billion to medical facilities that have adopted and successfully demonstrated meaningful use of certified electronic health record (EHR). Hospital organizations can increase cost savings by using the electronic components of EHRs to improve medical coding and reduce medical errors and transcription costs. Despite the incentives, some rural health care facilities are failing to progress. The purpose of this multiple case study was to explore the strategies rural hospital leaders used to implement an EHR. The target population consisted of rural hospital leaders who were involved in the successful implementation of an EHR in South Texas. The conceptual framework chosen for this study was the sociotechnical systems theory. Data were collected through telephone interviews using open-ended semistructured interviews with 5 participants from 4 rural hospitals who were involved in the EHR implementation. Data analysis occurred using Yin's 5-step process which includes compiling, disassembling, reassembling, interpreting, and concluding. Data analysis included collecting information from government websites, company documents, and open-ended information to develop recurring themes. Several themes emerged including ongoing training, provider buy-in, constant communication, use of super users, and workflow maintenance. The findings could influence social change by making the delivery of health care more efficient and improving quality, safety, and access to health care services for patients.

More than 4.9 million businesses exist in the United States, and leaders within these businesses have to acclimate to change. Clear and effective communication is vital to the success of an organization. According to scholars and health care leaders focusing on strategies to communicate change during organizational change is a critical aspect of sustainability and profitability. The conceptual framework of this study was communication theory. The purpose of this single case study was to explore successful strategies that some health care leaders used to communicate during organizational change in a health care organization in El Paso, Texas. The data collection process consisted of collecting data from semistructured interviews and organizational documents, and the analysis process included grouping key words and reconstructing data into themes. The 4 key themes that emerged from this process included building trust through organizational communication is critical during change, the use of technologies, as a tool for communication is key during change, 2-way communication needs to occur during organizational change, and communication about change is vital through comprehensive organizational meetings. Health care leaders provided insights on management and communication strategies and responsibilities leaders and employees go through during organizational change. The implications for positive social change include strategies to improve communication that could help health care leaders with their employees and their patients during organizational change, which could increase the profitability of the organization and potentially generate a more thriving and healthy community.

Background: Implementations of national electronic health record (EHR) were currently underway worldwide as a core objective of eHealth strategies. It was widely believed that implementation of EHR might lead to considerable financial savings. This paper aimed to conduct a systematic review to assess return-on-investment (ROI) of HER implementation and to identify areas with greatest potential to positive ROI for ongoing deliberation on continuous development of EHR. Methodology: An inclusive string was developed to search English paper published between January 2003 and June 2013. This paper only included studies meet the following criteria 1) Primary study; 2) Involve a computerized system with electronic health record; and 3) include some form of economic evaluation. Critical appraisal was undertaken and articles with higher quality were selected. Hard ROI and soft ROI defined for EHR implementation were adopted as outcome metrics to examine both tangible and intangible return of EHR implementation. Results: A total of 18 articles were examined for data extraction and synthesis. Most of the available evidences came from pre-post evaluation or cross-sectional analysis without uniform standards for reporting. Findings of 56% of the articles indicated that there is cost saving after EHR implementation while 17% of the articles indicated loss in totalrevenue. The remaining articles concluded that there is no association between cost reduction and EHR implementation. Among the defined hard ROI, most studies mentioned the positive effect in resource reduction. Some authors argued that the resource was reallocated to other initiatives and resulted in negligible cost saving. According to the selected literatures, evidences showed that EHR was able to achieve defined soft ROI, especially for improving caring process, but the overall outcome was subject to individual practice. Authors of 12 out of 18 articles have identified the factor leading to positive return and provided recommendation toward successful EHR implementation. Other than implying helpful EHR functions and promoting practice change, additional incentive on quality improvement and performance benchmarking should be considered. The organizations and EHR systems studied in the articles examined were vastly different; it would be desirable if a controlled study adopting EHR with uniform standards can be performed to evaluate the ROI of different clinical settings. Conclusions: The benefits of EHR are not guaranteed, it requires change of practice and substantial efforts. Healthcare industries have to equip themselves for implementing the new technology and to exploit the usage for better clinical outcome.
published_or_final_version
Public Health
Master
Master of Public Health

The landscape of the United States public school system was greatly improved upon with the creation of The Individuals with Disabilities Education Act of 2004 (IDEA 2004). This act established a standard that allowed all school aged children living with chronic illnesses to integrate into public school systems. This mandate currently impacts over 12 million children living with chronic illness including and not limited to asthma, seizure disorders, developmental delay, cystic fibrosis, traumatic brain injuries, anxiety and cancer. IDEA 2004 extended healthcare into public school systems and as a result, increased the average acuity of students that school nurses (SNs) care for. It is estimated that 15% of school-aged children miss 11 or more school days per year because of illness or injury demonstrating evidence of increased student acuity and a need to provide more appropriate care for these students in order to increase their time spent in the academic setting. Adequate SN and primary care provider (PCP) communication is essential to reduce absenteeism for this population and to ensure that students are safe during their time spent away from home and healthcare clinics. From this quality improvement project, more is understood pertaining to the communication patterns between SNs and PCPs and recommendations are provided in order to increase effective SN and PCP communication.

In healthcare there is a rapid development towards introducing and implementing a wide range of information technology (IT) to aim for higher quality and more effective care. A common health information system (Cambio Cosmic) has been implemented in Landstinget Kronoberg. Clinical microsystems are the frontline units where staff and pa-tient meet. When the conditions in the microsystems are changed, it is interesting to de-scribe and analyse the consequences.

The purpose of this study is to describe how health care staff uses a health information sys-tem and how they experience its functionality in their patient work. Initially, a literature re-view about the use of health information system was undertaken, followed by a qualitative case study based on interviews about how healthcare staff describes their reality. In March 2007 general practitioners, district nurses and practical nurses at the health care center in Markaryd were interviewed. The results were analysed using a modified microsystem the-ory. The analysis showed that the health care staff in Markaryd used Cambio Cosmic for medical record, time planning, cash handling, laboratory examinations and results, and medications. Apart from Cosmic, they used several other information systems IT- or pa-perbased.

The staff experienced that Cosmic did support their patient work, but technical deficiencies impeded use. The staff required a more rapid system, integration of systems and more per-sonal adaptations. A common health information system was seen as a strength in the care process. Co-operation between staff and with other caregivers was facilitated and Cosmic contributed to a more efficient work pattern. The patients could receive improved service and information. In general, the staff thought that they had access to the right information for the care of the patient, but improvements were needed for access to information at the right point of time. Cosmic was not used to improve work at the health care center. The staff expressed a positive attitude towards working with and in Cosmic. Based on the re-sult, improvements at both micro- and macrosystems levels are recommended.

Inom sjukvården sker en snabb utveckling med att implementera allt mer informationstek-nik (IT) i syfte att höja kvalitet och effektivitet inom sjukvården. Ett gemensamt vårdin-formationsssystem (Cambio Cosmic) har införts i Landstinget Kronoberg. Den plats i vår-dens frontlinje där patienter och vårdpersonal möts är ett kliniskt microsystem. När förut-sättningarna ändras i ett system är det intressant att analysera och beskriva konsekvenserna.

Syftet med denna rapport är att beskriva hur vårdpersonal använder ett IT-baserat vårdin-formationssystem och hur de upplever att det fungerar i patientarbetet. En litteraturstudie gjordes om användning av vårdinformationssystem. En fallstudie med intervjuer användes med en kvalitativ ansats för att samla in data om hur vårdpersonalen beskriver sin verklig-het. I mars 2007 intervjuades distriktsläkare, distriktsköterskor och undersköterskor på vårdcentralen i Markaryd, totalt 6 intervjuer, två av varje kategori. Resultatet analyserades utifrån en modifierad microsystemsteori. Vårdpersonalen i Markaryd använde Cambio Cosmics moduler för vårddokumentation, tidbokning, kassafunktion, provtagning och lä-kemedel. Utöver Cosmic användes även flera andra IT-stöd och papperssystem i patientar-betet.

Vårdpersonalen upplever att Cosmic fungerar som stöd i patientarbetet, men att tekniska brister är ett hinder i användningen och de efterfrågade ett snabbare system, systemintegre-ring och mer personliga anpassningar. I vårdprocessen upplevdes tillgången till en lands-tingsgemensam journal som en styrka. Samverkan mellan vårdpersonal och med andra vårdgivare underlättades och Cosmic bidrog till ett effektivare arbetssätt. Patienten kunde ges en förbättrad service och information. Överlag ansåg vårdpersonalen att de hade till-gång till rätt information för patientens vård, men för att ha tillgång till information i rätt tid behövdes förbättringar. Cosmic användes inte i förbättringsarbete på vårdcentralen. Vårdpersonalen på Markaryds vårdcentral gav uttryck för en positiv inställning till arbetet i Cosmic. Utifrån resultatet rekommenderas förbättringar på både micro- och macrosys-temsnivå.

Electronic Health Record (EHR) is an umbrella term encompassing demographics and health information of a patient from many different sources in a digital format. Deep learning has been used on EHRs in many successful studies and there is great potential in future implementations. In this study, diagnosis classification of EHRs with Multi-layer Perceptron models are studied. Two MLPs with different architectures are constructed and run on both a modified version of the EHR dataset and the raw data. A Random Forest is used as baseline for comparison. The MLPs are not successful in beating the baseline, with the best-performing MLP having a classification accuracy of 48.1%, which is 13.7 percentage points lower than that of the baseline. The results indicate that when the dataset is small, this approach should not be chosen. However, the dataset is growing over time and thus there is potential for continued research in the future.
Elektronisk patientjournal (EHR) är ett paraplybegrepp som används för att beskriva en digital samling av demografisk och medicinsk data från olika källor för en patient. Det finns stor potential i användandet av djupinlärning på dessa journaler och många framgångsrika studier har redan gjorts på området. I denna studie undersöks diagnosklassificering av elektroniska patientjournaler med Multi-layer perceptronmodeller. Två MLP-modeller av olika arkitekturer presenteras. Dessa körs på både en anpassad version av EHR-datamängden och på den råa EHR-datan. En Random Forest-modell används som baslinje för jämförelse. MLP-modellerna lyckas inte överträffa baslinjen, då den bästa MLP-modellen ger en klassifikationsnoggrannhet på 48,1%, vilket är 13,7 procentenheter mindre än baslinjens. Resultaten visar att en liten datamängd indikerar att djupinlärning bör väljas bort för denna typ av problem. Datamängden växer dock över tid, vilket gör områdetattraktivt för framtida studier.

On the 26th of May 2021 the new regulation for medical devices, MDR 2017/745, will come into force. The underlying incentives to go from the medical device directive (MDD 93/42/EEC) to MDR are a series of adverse events involving medical devices. The main goal of MDR is to strengthen and improve the already existing legislation and thus will entail large changes for manufactures, one of them being manufacturers of Electronic Health Record (EHR) systems. For medical software, such as EHR systems, the new regulation will imply an upgrade in risk classification. This upgrade will bring additional requirements for EHR manufacturers. Furthermore, the released guidelines have been insufficient regarding the specific requirements for medical device software and thus EHR manufacturers are in need of tools and guidance to fulfill MDR. This thesis examines the new regulation for medical devices and thus identifies main requirements for EHR manufacturers. A qualitative approach was conducted comprising a literature study as well as a document study of the medical device regulation along with interviews with experts within the field of medtech regulatory affairs and quality assurance. The information gathered was analyzed to create a process description on how EHR manufacturers are to fulfill MDR. The process description is a general outline and presents the main steps on the route to be compliant with MDR in a recommended order of execution. The main steps are: divide the system into modules, qualify the modules, classify the modules, implement a quality management system, compile a technical documentation, compile the declaration of conformity, undergo a conformity assessment and finally, obtain the CE-mark. To each of the main steps additional documentation provides further information and clarification. The process description functions as a useful tool for EHR manufacturers towards regulatory fulfillment. Even though the process description is created for EHR manufacturers, it can be useful for other medical device software manufacturers. The process description provides an overview of the path to a CE mark and functions as a guidance. It can be used in educational purposes as well as to serve as a checklist for the experienced manufacturer to make sure everything is covered. However, it is not sufficient to rely solely on the process description in order to be in full compliance with MDR. Moreover, there is still a need for further clarifications from the European Commission regarding specific requirements on medical device software.

The use of Electronic Health Records (EHR) for reporting patient data has been widely adopted by healthcare providers. This data can encompass many forms of medical information such as disease symptoms, results from laboratory tests, ICD-10 classes and other information from patients. Structured EHR data is often high-dimensional and contain many missing values, which impose a complication to many computing problems. Detecting meaningful structures in EHR data could provide meaningful insights in diagnose detection and in development of medical decision support systems. In this work, a subset of EHR data from patient questionnaires is explored through two well-known clustering algorithms: K-Means and Agglomerative Hierarchical. The algorithms were tested on different types of data, primarily raw data and data where missing values have been imputed using different imputation techniques. The primary evaluation index for the clustering algorithms was the silhouette value using euclidean and cosine distance measures. The result showed that natural groupings most likely exist in the data set. Hierarchical clustering created higher quality clusters than k-means, and the cosine measure yielded a good interpretation of distance. The data imputation imposed large effects to the data and likewise to the clustering results, and other or more sophisticated techniques are needed for handling missing values in the data set.
Användandet av digitala journaler för att rapportera patientdata har ökat i takt med digitaliseringen av vården. Dessa data kan innehålla många typer av medicinsk information så som sjukdomssymptom, labbresultat, ICD-10 diagnoskoder och annan patientinformation. EHR data är vanligtvis högdimensionell och innehåller saknade värden, vilket kan leda till beräkningssvårigheter i ett digitalt format. Att upptäcka grupperingar i sådana patientdata kan ge värdefulla insikter inom diagnosprediktion och i utveckling av medicinska beslutsstöd. I detta arbete så undersöker vi en delmängd av digital patientdata som innehåller patientsvar på sjukdomsfrågor. Detta dataset undersöks genom att applicera två populära klustringsalgoritmer: k-means och agglomerativ hierarkisk klustring. Algoritmerna är ställda mot varandra och på olika typer av dataset, primärt rådata och två dataset där saknade värden har ersatts genom imputationstekniker. Det primära utvärderingsmåttet för klustringsalgoritmerna var silhuettvärdet tillsammans med beräknandet av ett euklidiskt distansmått och ett cosinusmått. Resultatet visar att naturliga grupperingar med stor sannolikhet finns att hitta i datasetet. Hierarkisk klustring visade på en högre klusterkvalitet än k-means, och cosinusmåttet var att föredra för detta dataset. Imputation av saknade data ledde till stora förändringar på datastrukturen och således på resultatet av klustringsexperimenten, vilket tyder på att andra och mer avancerade dataspecifika imputationstekniker är att föredra.

I dagens samhälle är det vanligt att patienter söker vård hos olika vårdgivare, vilket resulterar i att vårdinformationen blir splittrad och allt högre krav ställs på de datoriserade journalsystemen. Till exempel ska de stödja ett processorienterat arbetssätt för att samla information från samma vårdprocess. Vårdinformationen måste därför vara tillgänglig över organisationsgränser och olika journalsystem måste kunna kommunicera med varandra, där en ökad tillgänglighet ställer högre krav på informationssäkerhet och behörighetskontroll. Journalsystemen bör, för att uppfylla dessa krav, utvecklas enligt standarder och riktlinjer.

Det finns ett flertal nationella och internationella organisationer som arbetar med att ta fram standarder och riktlinjer för hur journalsystem bör utvecklas. Problemet är att dessa arbeten sker på olika nivåer och gäller olika delar av journalsystemen. Det är därmed en stor utmaning för journalleverantörer att förhålla sig till dessa arbeten. Syftet med det här examensarbetet har varit att utreda hur utvalda, svenska och europeiska, standardiseringsarbeten förhåller sig till varandra samt att avgöra på vilket sätt de är av relevans för journalleverantörer. Dessutom har syftet varit att framställa en prototyp av ett IT-stöd för processorienterad vårddokumentation.

En kvalitativ litteraturstudie har i det här examensarbetet resulterat i en sammanställning av de utvalda standardiseringsarbetena. Arbetena hanterar främst områden som kan användas för att ena vårdprocessen, exempel på dessa är behörighetskontroll och standardiserad kommunikation med informationsspecifikationer eller arketyper. SAMBA har tagit fram en processmodell som beskriver vårdprocessen. Baserat på denna modell och krav från standardiseringsarbetena har vi framställt ett förslag på ett IT-stöd för processorienterad vårddokumentation.

[EN] Healthcare domain produces and consumes big quantities of people's health data. Although data exchange is the norm rather than the exception, being able to access to all patient data is still far from achieved. Current developments such as personal health records will introduce even more data and complexity to the Electronic Health Records (EHR). Achieving semantic interoperability is one of the biggest challenges to overcome in order to benefit from all the information contained in the distributed EHR. This requires that the semantics of the information can be understood by all involved parties. It has been stablished that three layers are needed to achieve semantic interoperability: Reference models, clinical models (archetypes), and clinical terminologies. As seen in the literature, information models (reference models and clinical models) are lacking methodologies and tools to improve EHR systems and to develop new systems that can be semantically interoperable. The purpose of this thesis is to provide methodologies and tools for advancing the use of archetypes in three different scenarios: - Archetype definition over specifications with no dual model architecture native support. Any EHR architecture that directly or indirectly has the notion of detailed clinical models (such as HL7 CDA templates) can be potentially used as a reference model for archetype definition. This allows transforming single-model architectures (which contain only a reference model) into dual-model architectures (reference model with archetypes). A set of methodologies and tools has been developed to support the definition of archetypes from multiple reference models. - Data transformation. A complete methodology and tools are proposed to deal with the transformation of legacy data into XML documents compliant with the archetype and the underlying reference model. If the reference model is a standard then the transformation is a standardization process. The methodologies and tools allow both the transformation of legacy data and the transformation of data between different EHR standards. - Automatic generation of implementation guides and reference materials from archetypes. A methodology for the automatic generation of a set of reference materials is provided. These materials are useful for the development and use of EHR systems. These reference materials include data validators, example instances, implementation guides, human-readable formal rules, sample forms, mindmaps, etc. These reference materials can be combined and organized in different ways to adapt to different types of users (clinical or information technology staff). This way, users can include the detailed clinical model in their organization workflow and cooperate in the model definition. These methodologies and tools put clinical models as a key part of the system. The set of presented methodologies and tools ease the achievement of semantic interoperability by providing means for the semantic description, normalization, and validation of existing and new systems.
[ES] El sector sanitario produce y consume una gran cantidad de datos sobre la salud de las personas. La necesidad de intercambiar esta información es una norma más que una excepción, aunque este objetivo está lejos de ser alcanzado. Actualmente estamos viviendo avances como la medicina personalizada que incrementarán aún más el tamaño y complejidad de la Historia Clínica Electrónica (HCE). La consecución de altos grados de interoperabilidad semántica es uno de los principales retos para aprovechar al máximo toda la información contenida en las HCEs. Esto a su vez requiere una representación fiel de la información de tal forma que asegure la consistencia de su significado entre todos los agentes involucrados. Actualmente está reconocido que para la representación del significado clínico necesitamos tres tipos de artefactos: modelos de referencia, modelos clínicos (arquetipos) y terminologías. En el caso concreto de los modelos de información (modelos de referencia y modelos clínicos) se observa en la literatura una falta de metodologías y herramientas que faciliten su uso tanto para la mejora de sistemas de HCE ya existentes como en el desarrollo de nuevos sistemas con altos niveles de interoperabilidad semántica. Esta tesis tiene como propósito proporcionar metodologías y herramientas para el uso avanzado de arquetipos en tres escenarios diferentes: - Definición de arquetipos sobre especificaciones sin soporte nativo al modelo dual. Cualquier arquitectura de HCE que posea directa o indirectamente la noción de modelos clínicos detallados (por ejemplo, las plantillas en HL7 CDA) puede ser potencialmente usada como modelo de referencia para la definición de arquetipos. Con esto se consigue transformar arquitecturas de HCE de modelo único (solo con modelo de referencia) en arquitecturas de doble modelo (modelo de referencia + arquetipos). Se han desarrollado metodologías y herramientas que faciliten a los editores de arquetipos el soporte a múltiples modelos de referencia. - Transformación de datos. Se propone una metodología y herramientas para la transformación de datos ya existentes a documentos XML conformes con los arquetipos y el modelo de referencia subyacente. Si el modelo de referencia es un estándar entonces la transformación será un proceso de estandarización de datos. La metodología y herramientas permiten tanto la transformación de datos no estandarizados como la transformación de datos entre diferentes estándares. - Generación automática de guías de implementación y artefactos procesables a partir de arquetipos. Se aporta una metodología para la generación automática de un conjunto de materiales de referencia de utilidad en el desarrollo y uso de sistemas de HCE, concretamente validadores de datos, instancias de ejemplo, guías de implementación , reglas formales legibles por humanos, formularios de ejemplo, mindmaps, etc. Estos materiales pueden ser combinados y organizados de diferentes modos para facilitar que los diferentes tipos de usuarios (clínicos, técnicos) puedan incluir los modelos clínicos detallados en el flujo de trabajo de su sistema y colaborar en su definición. Estas metodologías y herramientas ponen los modelos clínicos como una parte clave en el sistema. El conjunto de las metodologías y herramientas presentadas facilitan la consecución de la interoperabilidad semántica al proveer medios para la descripción semántica, normalización y validación tanto de sistemas nuevos como ya existentes.
[CAT] El sector sanitari produeix i consumeix una gran quantitat de dades sobre la salut de les persones. La necessitat d'intercanviar aquesta informació és una norma més que una excepció, encara que aquest objectiu està lluny de ser aconseguit. Actualment estem vivint avanços com la medicina personalitzada que incrementaran encara més la grandària i complexitat de la Història Clínica Electrònica (HCE). La consecució d'alts graus d'interoperabilitat semàntica és un dels principals reptes per a aprofitar al màxim tota la informació continguda en les HCEs. Açò, per la seua banda, requereix una representació fidel de la informació de tal forma que assegure la consistència del seu significat entre tots els agents involucrats. Actualment està reconegut que per a la representació del significat clínic necessitem tres tipus d'artefactes: models de referència, models clínics (arquetips) i terminologies. En el cas concret dels models d'informació (models de referència i models clínics) s'observa en la literatura una mancança de metodologies i eines que en faciliten l'ús tant per a la millora de sistemes de HCE ja existents com per al desenvolupament de nous sistemes amb alts nivells d'interoperabilitat semàntica. Aquesta tesi té com a propòsit proporcionar metodologies i eines per a l'ús avançat d'arquetips en tres escenaris diferents: - Definició d'arquetips sobre especificacions sense suport natiu al model dual. Qualsevol arquitectura de HCE que posseïsca directa o indirectament la noció de models clínics detallats (per exemple, les plantilles en HL7 CDA) pot ser potencialment usada com a model de referència per a la definició d'arquetips. Amb açò s'aconsegueix transformar arquitectures de HCE de model únic (solament amb model de referència) en arquitectures de doble model (model de referència + arquetips). S'han desenvolupat metodologies i eines que faciliten als editors d'arquetips el suport a múltiples models de referència. - Transformació de dades. Es proposa una metodologia i eines per a la transformació de dades ja existents a documents XML conformes amb els arquetips i el model de referència subjacent. Si el model de referència és un estàndard llavors la transformació serà un procés d'estandardització de dades. La metodologia i eines permeten tant la transformació de dades no estandarditzades com la transformació de dades entre diferents estàndards. - Generació automàtica de guies d'implementació i artefactes processables a partir d'arquetips. S'hi inclou una metodologia per a la generació automàtica d'un conjunt de materials de referència d'utilitat en el desenvolupament i ús de sistemes de HCE, concretament validadors de dades, instàncies d'exemple, guies d'implementació, regles formals llegibles per humans, formularis d'exemple, mapes mentals, etc. Aquests materials poden ser combinats i organitzats de diferents maneres per a facilitar que els diferents tipus d'usuaris (clínics, tècnics) puguen incloure els models clínics detallats en el flux de treball del seu sistema i col·laborar en la seua definició. Aquestes metodologies i eines posen els models clínics com una part clau del sistemes. El conjunt de les metodologies i eines presentades faciliten la consecució de la interoperabilitat semàntica en proveir mitjans per a la seua descripció semàntica, normalització i validació tant de sistemes nous com ja existents.
Boscá Tomás, D. (2016). DETAILED CLINICAL MODELS AND THEIR RELATION WITH ELECTRONIC HEALTH RECORDS [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/62174
TESIS

Health and sociological indicators confirm that life expectancy is increasing, and so, the years that patients have to live with chronic diseases and co-morbidities. Type 2 Diabetes is one of the most common chronic diseases, specially linked to overweight and ages over sixty. As a metabolic disease, Type 2 Diabetes affects multiple organs by causing damage in blood vessels and nervous system at micro and macro scale. Mortality of subjects with diabetes is three times higher than the mortality for subjects with other chronic diseases. On the one hand, the management of diabetes is focused on the maintenance of the blood glucose levels under a threshold by the prescription of anti-diabetic drugs and a combination of healthy food habits and moderate physical activity. Recent studies have demonstrated the effectiveness of new strategies to delay and even prevent the onset of Type 2 Diabetes by a combination of active and healthy lifestyle on cohorts of mid to high risk subjects. On the other hand, prospective research has been driven on large groups of population to build risk scores which aim to obtain a rule for the classification of patients according to the odds for developing the disease. Currently there are more than two hundred models and risk scores for doing this, but a few have been properly evaluated in external groups and, to date, none of them has been tested on a population based study. The research study presented in this doctoral thesis strives to use externally validated risk scores for the prediction and detection of Type 2 Diabetes on a population data base in Hospital La Fe (Valencia, Spain). The study hypothesis is that the integration of existing prediction and detection risk scores on Electronic Health Records increases the early-detection of high risk cases. To evaluate this hypothesis three studies on the clinical, user and technology dimensions have been driven to evaluate the extent to which the models and the hospital is ready to exploit such models to identify high risk groups and drive efficient preventive strategies. The findings presented in this thesis suggest that Electronic Health Records are not prepared to massively feed risk models. Some of the evaluated models have shown a good classification performance, which accompanied to the well-acceptance of web-based tools and the acceptable technical performance of the information and communication technology system, suggests that after some work these models can effectively drive a new paradigm of active screening for Type 2 Diabetes.
Los indicadores de salud y sociológicos confirman que la esperanza de vida está aumentando, y por lo tanto, los años que los pacientes tienen que vivir con enfermedades crónicas y comorbilidades. Diabetes tipo 2 es una de las enfermedades crónicas más comunes, especialmente relacionadas con el sobrepeso y edades superiores a los sesenta años. Como enfermedad metabólica, la diabetes tipo 2 afecta a múltiples órganos causando daño en los vasos sanguíneos y el sistema nervioso a escala micro y macro. La mortalidad de sujetos con diabetes es tres veces mayor que la mortalidad de sujetos con otras enfermedades crónicas. Por un lado, la estrategia de manejo se centra en el mantenimiento de los niveles de glucosa en sangre bajo un umbral mediante la prescripción de fármacos antidiabéticos y una combinación de hábitos alimentarios saludables y actividad física moderada. Estudios recientes han demostrado la eficacia de nuevas estrategias para retrasar e incluso prevenir la aparición de la diabetes tipo 2 mediante una combinación de estilo de vida activo y saludable en cohortes de sujetos de riesgo medio a alto. Por otro lado, la investigación prospectiva se ha dirigido a grupos de la población para construir modelos de riesgo que pretenden obtener una regla para la clasificación de las personas según las probabilidades de desarrollar la enfermedad. Actualmente hay más de doscientos modelos de riesgo para hacer esta identificación, no obstante la inmensa mayoría no han sido debidamente evaluados en grupos externos y, hasta la fecha, ninguno de ellos ha sido probado en un estudio poblacional. El estudio de investigación presentado en esta tesis doctoral pretende utilizar modelos riesgo validados externamente para la predicción y detección de la Diabetes Tipo 2 en una base de datos poblacional del Hospital La Fe de Valencia (España). La hipótesis del estudio es que la integración de los modelos de riesgo de predicción y detección existentes la práctica clínica aumenta la detección temprana de casos de alto riesgo. Para evaluar esta hipótesis, se han realizado tres estudios sobre las dimensiones clínicas, del usuario y de la tecnología para evaluar hasta qué punto los modelos y el hospital están dispuestos a explotar dichos modelos para identificar grupos de alto riesgo y conducir estrategias preventivas eficaces. Los hallazgos presentados en esta tesis sugieren que los registros de salud electrónicos no están preparados para alimentar masivamente modelos de riesgo. Algunos de los modelos evaluados han demostrado un buen desempeño de clasificación, lo que acompañó a la buena aceptación de herramientas basadas en la web y el desempeño técnico aceptable del sistema de tecnología de información y comunicación, sugiere que después de algún trabajo estos modelos pueden conducir un nuevo paradigma de la detección activa de la Diabetes Tipo 2.
Els indicadors sociològics i de salut confirmen un augment en l'esperança de vida, i per tant, dels anys que les persones han de viure amb malalties cròniques i comorbiditats. la diabetis de tipus 2 és una de les malalties cròniques més comunes, especialment relacionades amb l'excés de pes i edats superiors als seixanta anys. Com a malaltia metabòlica, la diabetis de tipus 2 afecta múltiples òrgans causant dany als vasos sanguinis i el sistema nerviós a escala micro i macro. La mortalitat de subjectes amb diabetis és tres vegades superior a la mortalitat de subjectes amb altres malalties cròniques. D'una banda, l'estratègia de maneig se centra en el manteniment dels nivells de glucosa en sang sota un llindar mitjançant la prescripció de fàrmacs antidiabètics i una combinació d'hàbits alimentaris saludables i activitat física moderada. Estudis recents han demostrat l'eficàcia de noves estratègies per a retardar i fins i tot prevenir l'aparició de la diabetis de tipus 2 mitjançant una combinació d'estil de vida actiu i saludable en cohorts de subjectes de risc mitjà a alt. D'altra banda, la investigació prospectiva s'ha dirigit a grups específics de la població per construir models de risc que pretenen obtenir una regla per a la classificació de les persones segons les probabilitats de desenvolupar la malaltia. Actualment hi ha més de dos-cents models de risc per fer aquesta identificació, però la immensa majoria no han estat degudament avaluats en grups externs i, fins ara, cap d'ells ha estat provat en un estudi poblacional. L'estudi d'investigació presentat en aquesta tesi doctoral utilitza models de risc validats externament per a la predicció i detecció de diabetis de tipus 2 en una base de dades poblacional de l'Hospital La Fe de València (Espanya). La hipòtesi de l'estudi és que la integració dels models de risc de predicció i detecció existents la pràctica clínica augmenta la detecció de casos d'alt risc. Per avaluar aquesta hipòtesi, s'han realitzat tres estudis sobre les dimensions clíniques, de l'usuari i de la tecnologia per avaluar fins a quin punt els models i l'hospital estan disposats a explotar aquests models per identificar grups d'alt risc i conduir estratègies preventives. Les troballes presentades sugereixen que els registres de salut electrònics no estan preparats per alimentar massivament models de risc. Alguns dels models avaluats han demostrat una bona classificació, el que va acompanyar a la bona acceptació d'eines basades en el web i el rendiment tècnic acceptable del sistema de tecnologia d'informació i comunicacions implementat. La conclusió es que encara es necesari treball per que aquests models poden conduir un nou paradigma de la detecció activa de la diabetis de tipus 2.
Martínez Millana, A. (2017). ASSESSMENT OF RISK SCORES FOR THE PREDICTION AND DETECTION OF TYPE 2 DIABETES MELLITUS IN CLINICAL SETTINGS [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/86209
TESIS

The European health care is facing challenges with an increasing ageing population, with a higher frequency of chronic diseases, which have resulted in rising health care costs. Meanwhile, the trend shows how patients and citizens are becoming more active in their personal health care, with the number of existing doctors and nurses subsiding furthermore entailing problems. The area of eHealth, which involves information and communication technologies with health care, is hence seen as a partial long-term solution and is considered being a rapidly growing market both in Sweden, but also in Europe. eHealth services further consider to promote increased access, mobility and interoperability in the health care, but the lack of wholehearted commitment, financial support and complex EHR-systems in Sweden's municipalities and county councils might partially impeding down the development. The purpose of this report is therefore targeting to explore, identify and analyze prominent aspects for the continued development of the Swedish health care and eHealth services. The study also examines what subsequent benefits an implementation of an eHealth service entails, which also has been related to the identified prominent aspects. This master thesis is based on a thorough literature review extracted from a theoretical framework including an interoperability-, security-, mobility- and business-modeling perspective, which are used as a foundation for the building of a set of hypotheses, which are subsequently verified with the aid of gathered empirics. The empirics are obtained from 10 semi-structured qualitative interviews, as well as two case studies, which together resulted in key-findings and conclusions. Firstly, in relation to the interoperability perspective, it became clear how there should exist both a technical and social interoperability that communicate with each other. The EHR-systems of today are often considered difficult to learn, non-intuitive and lacking interfaces that are user-friendly designed for the end-user. Increased interoperability was also seen as enabling and simplifying the access to the patient’s medical history, which the EHR-system TakeCare evidently demonstrated. Furthermore, it was acknowledged how there is no correlation between the increased time spent by health care professionals with administrative tasks and documentation with an increased interoperability. It also emerged that patients and the dominant part of the population had either no or very limited knowledge regarding the underlying security and overall management of personal health information in health care. Patients instead often blindly trust the Swedish health care system being secure, and prioritizing other things during medical appointments. The knowledge of security issues in the health care is predicted to increase among patients if they in the future would obtain full access to their own medical records. There is also a general opinion among health care professionals and related instances how new security risks will arise alongside the eHealth wave, with a particular concern for the increasing involvement of mobile devices. Relationships between an increased interoperability also seem to favor increased mobility in health care, but security aspects often prevent the mobility development. Finally, it was unanimously espoused how non-financial values must not be ignored, where the on-going debate argues whether what real impact these non-financial values have, where inter alia strict budgets and large gaps between the decision-makers and end-users appeared as issues. Similar arguments were encountered regarding the actual impact of the opinions of patients in relation to business modeling, where a tripartite-problem and the patients’ limited access to their medical records was partly seen as a primary issue. Secondly, the case studies demonstrated how a transition to the EHR-system TakeCare generally did result in cost- and resource savings in terms of local servers, IT-maintenance and inventory management. The TakeCare implementation also led to an increased visibility among health care centers by enabling and simplifying the access to patient medical history. Increased communication, awareness, and more effective internal processes due to integrated modules and direct connections to ePrescriptions could also be accessed from the TakeCare transition. Finally, it emerged that relations existed between simplified access to the patient’s medical history and how it subsequently resulted in an increased interoperability. A correlation was also seen as the health care become generally more mobile due to increased interoperability.
Hälso- och sjukvården i Europa står inför utmaningar i och med en stigande åldersgrupp med en större andel kroniska sjukdomar, vilket resulterat i stegrande sjukvårdskostnader. Samtidigt ses en trend i hur patienter och medborgare börjar bli mer aktiva i sin egen vård och efterfrågan på sjukvårdspersonal ökar, med ökande utmaningar som följd. eHälsa-området, vilket involverar informations- och kommunikationsteknik inom sjukvården, ses därför som en potentiell långsiktig del-lösning och anses samtidigt vara ett starkt växande område i Sverige, men också på den övriga europeiska marknaden. eHälsa betraktas vidare främja en ökad åtkomst, mobilitet och interoperabilitet inom sjukvården, men bristen på helhjärtat engagemang, finansiellt stöd och det stora antal komplexa journalsystem i Sveriges olika kommuner och landsting ses delvis ligga till grund för en bromsad utveckling. Syftet med denna rapport är därför att undersöka, kartlägga och analysera de mest centrala aspekterna för den fortsatta utvecklingen av svensk sjukvård och eHälso-tjänster. Studien undersöker även vad implement av en eHälso-tjänst praktiskt har medfört, med ett fokus på journalsystem där de enskilda förändringarna även har relaterats till de identifierade centrala aspekterna. Examensarbetet är baserat på en gedigen litteraturstudie som utifrån ett teoretiskt ramverk inkluderande ett interoperabilitets-, säkerhets-, mobilitets- och affärsmoduleringsperspektiv ligger till grund för framtagandet av hypoteser som sedan verifierats med hjälp av empiriskt insamlad information. Empirin är erhållen från tio semi-strukturerande kvalitativa intervjuer, samt två fallstudier, vilka tillsammans har resulterat i ett flertal slutsatser. Utifrån ett interoperabilitetsperspektiv framgick det hur det bör finnas både en teknisk och social interoperabilitet som kommunicerar med varandra, då journalsystem idag anses vara svåra att lära sig, icke intuitiva och ej användarvänligt utformade för slutanvändaren. Ökad interoperabilitet ses även möjliggöra och förenkla åtkomsten av patienthistorik, vilket journalsystemet TakeCare tydligt påvisat. Vidare kunde det konstateras att det inte finns en korrelation mellan den progressivt ökande avsatta tiden som sjukvårdspersonal idag tillbringar med administrativa uppgifter och dokumentation med en förhöjd interoperabilitet. Det framkom även att patienter har väldigt liten eller obefintlig kunskap rörande den underliggande säkerheten och hanteringen av personlig information i sjukvården, då de ofta blint litar på att svensk sjukvård anses vara säker samt att patienter prioriterar annat vid läkarbesök. Kunskaper om säkerheten i sjukvården bland patienterna anses dock öka ifall de i framtiden får tillgång till sin journal. Det finns även en allmän oro bland sjukvårdspersonal och närbesläktade instanser för att nya säkerhetsrisker kommer att uppstå i och med eHälsa-vågen, med ett särskilt orosmoln för den ökande användningen av mobila enheter. Relationer mellan hur ökad interoperabilitet även gynnar förhöjd mobilitet sågs även förekomma, men att det ofta samtidigt är säkerhetsaspekter som hindrar den mobila utvecklingen. Avslutningsvis förespråkades det hur icke-finansiella värden inte får bli ignorerade, men problemet kring hur verkningsfull dess faktiska påverkan är, relateras bland annat till strikta budgetar samt stora avstånd mellan beslutstagare och slutanvändare. Liknande argument påträffades angående den faktiska inverkan av åsikter från patienter vid affärsmodulering, där ett trepartsproblem och patienternas begränsade åtkomst till sina journaler delvis sågs ligga till grund. Fallstudierna påvisade hur övergången till journalsystemet TakeCare generellt har lett till resursbesparingar i form av lokala servrars underhåll och lageranvändning, samt en ökad synlighet i vården med förbättrad tillgång till patienthistorik jämfört med tidigare journalsystem. En ökad kommunikation och medvetenhet samt effektivare interna processer på grund av integrerade moduler och direktkoppling till eRecept kunde även påvisas. Slutligen framgick det att relationer förekom mellan den ökande åtkomsten av patienthistorik och andra journaler, och hur förhöjd interoperabilitet medfört detta. Samband kunde även ses hur ökad interoperabilitet positivt gynnar mobiliteten i sjukvården.

Background Adverse drug events (ADE) are leading cause of death. Current pharmacosurveillance methods rely on passive reporting to monitor drug safety, but this is slow and many ADEs are unreported. Moreover, physicians regularly prescribe drugs for indications for which they were never tested (off-label use), despite some highly-publicized associations with ADEs. We urgently need timely pharmacosurveillance methods to monitor drug safety and effectiveness for on- and off-label uses. Electronic health records (EHR) may help fill this void if they document the reasons for drug prescription (treatment indications) and discontinuation (e.g. adverse drug event, ineffectiveness). Objectives 1) To determine the accuracy of an EHR system in documenting orders for drug discontinuation and dose changes of prescription drugs. 2) To determine the sensitivity and positive predictive value of using an EHR to document treatment indications at the time of prescribing. 3) To evaluate the prevalence of off-label prescribing and its drug, patient and physician determinants in primary care. 4) To determine the association between off-label use and ADEs. Methods I conducted four studies using the Medical Office of the XXI century (MOXXI) EHR system, developed by the McGill clinical and health informatics research group. First, I conducted a validation study to assess the sensitivity, specificity, positive and negative predictive value of the MOXXI EHR system in documenting prescription drug discontinuation and dose-change orders by comparing with information from physician-facilitated chart review. Second, I assessed the sensitivity and the positive predictive value of MOXXI EHR in documenting treatment indications. Third, I estimated the prevalence of off-label prescribing and assessed the strength of scientific evidence for off-label use. Moreover, the drug, patient and physician determinants of off-label prescribing were assessed. Fourth, I assessed the association between off-label use and ADE using incident drug prescriptions, treatment indications and ADE data collected using an EHR. Results Manuscript 1 The sensitivity of the EHR in identifying physician-initiated drug discontinuations and dose-changes was 67.0% (95% CI: 54.1, 77.7), the specificity was 99.7% (95% CI: 99.5, 99.9), and the positive predictive value was 97.3% (95% CI: 95.6, 98.7). Manuscript 2 The sensitivity of the EHR treatment indication was 98.5% (95% CI; 96.5%, 99.5%) and the PPV of the system in identifying the treatment indication was 97.0% (95% CI; 94.2%, 98.6%). Manuscript 3 The prevalence of off-label use was 11.0% of 253,347 prescriptions written to 50,823 patients. 79.0% of off-label prescriptions lacked strong scientific evidence. Off-label use was highest for CNS drugs (26.3%), including anticonvulsants (67%), antipsychotics (44%), and antidepressants (33%). Higher risk of off-label use was demonstrated in drugs with 1-2 approved indications, older drugs, in women and in physicians with less evidence-based orientation. Manuscript 4 Off-label use and off-label use without strong scientific evidence had higher risk of ADE compared to on-label use [HR, 1.43 (95% CI, 1.29, 1.59) and HR, 1.53 (95% CI, 1.37, 1.72), respectively]. Younger patients, women, and patients who received ≥8 drugs or anti-infective drugs had increased ADE risk. Conclusion I have shown for the first time that an EHR system can accurately document physician-identified treatment indications and adverse drug events and other treatment outcomes. The treatment indication data could measure prevalence of off-label use. In addition, the treatment indication data, combined with drug treatment outcome data, could create a novel pharmacosurveillance tool. Moreover, I demonstrated that off-label prescribing is an independent determinant of ADEs. Future EHRs should incorporate treatment indication and treatment outcome features to monitor the safety and effectiveness of on- and off-label uses of drugs.
Contexte Les effets indésirables des médicaments (EIM) sont une cause importante de mortalité. Les méthodes actuelles de pharmacovigilance sous-estiment l'incidence des EIM et sont inefficientes. De plus, les médecins prescrivent souvent des médicaments pour des indications pour lesquelles ils n'ont pas été approuvés (usage non indiqué), une pratique associée à des EIM hautement médiatisés. Il y a donc un urgent besoin de développer de nouvelles méthodes de pharmacovigilance. À cette fin, les dossiers de santé électroniques (DSE) pourraient être utiles, notamment si l'indication de traitement et la raison justifiant l'arrêt d'un médicament y sont documentées.Objectifs1) Déterminer l'exactitude d'un DSE à documenter les arrêts de traitement médicamenteux; 2) Déterminer la sensibilité et la valeur prédictive positive d'un DSE à documenter les indications de traitement; 3) Évaluer la prévalence des prescriptions non indiquées en soins primaires et les déterminants y étant associées. 4) Déterminer l'association entre l'utilisation non indiquée des médicaments et les EIM. Méthodes Pour atteindre ces objectifs de recherche, j'ai réalisé quatre études en utilisant le DSE Medical Office of the XXI century (MOXXI). Premièrement, j'ai mené une étude de validation afin d'évaluer la sensibilité, la spécificité et les valeurs prédictives positive (VPP) et négative (VPN) du DSE MOXXI à documenter les ordonnance d'arrêt de traitement. Deuxièmement, j'ai mené une étude de validation afin d'évaluer la sensibilité et la VPP de MOXXI à documenter les indications de traitement. Troisièmement, j'ai estimé la prévalence de l'usage non indiqué des médicaments en soins primaires, ainsi que la robustesse des données supportant ce type d'usage. Quatrièmement, j'ai utilisé MOXXI afin d'évaluer l'association entre l'usage non indiqué des médicaments et les EIM. Résultats Manuscrit 1 La sensibilité de MOXXI à identifier des arrêts de traitements est de 67,0% (IC à 95%: 54,1 - 77,7), la spécificité est de 99,7% (IC 95%: 99,5, 99,9), la VPP est de 97,3% (IC à 95%: 95,6 - 98,7). Manuscrit 2 La sensibilité de l'indication de traitement documentée dans MOXXI était de 98,5% (IC à 95%; 96,5% - 99,5%) et sa VPP était de 97,0% (IC à 95%, 94,2% - 98,6%). Manuscrit 3 La prévalence de l'usage non indiqué des médicaments est de 11,0% parmi 253 347 prescriptions reçues par 50 823 patients. On estime que 79,0% des prescriptions non indiquées ne sont pas justifiées empiriquement. L'usage non indiqué des médicaments est le plus élevé pour les médicaments du système nerveux central (26,3%), dont les anticonvulsivants (66,6%), les antipsychotiques (43,8%) et les antidépresseurs (33,4%). Des taux élevés d'usages non indiqués des médicaments ont été démontrés pour les médicaments n'ayant que 1 ou 2 indications approuvées, les médicaments plus anciens, chez les femmes et pour les médecins plus empiristes. Manuscrit 4 Le taux d'EIM associé à un usage non indiqué des médicaments (19.8/10 000 personnes-mois) est plus élevé que celui pour les usages indiqués (12,5 pour 10.000 personnes-mois) [HR : 1,43; IC à 95% : 1,29 - 1,59)]. Les usages non indiqués, non justifiés empiriquement, ont un taux encore plus élevé d'EIM (21,8 pour 10.000 personnes-mois) par rapport aux usages indiqués [HR : 1,53; IC à 95% : 1,37 - 1,72]). Les patients plus jeunes, les femmes et les patients ayant reçu ≥8 médicaments ou des agents anti-infectieux ont un risque accru d'EIM. Conclusion Un DSE peut documenter avec précision les indications de traitement, les EIM et d'autres résultats de traitement. Les données relatives à l'indication de traitement pourraient être combinées à celles relatives aux résultats cliniques afin de créer un nouvel outil de pharmacosurveillance. L'usage non indiqué des médicaments est un déterminant indépendant des EIM. Les DSE devront intégrer les indications et les résultats de traitements afin de faciliter l'évaluation de la sécurité et de l'efficacité des médicaments.

The task of ensuring Patient Safety is, more than ever, central in Healthcare. The report “To Err is Human” [Kohn et al. 2000], was revealing alarming numbers of incidents, injuries and deaths caused by deficiencies in healthcare activities. The book initiated assessment and change of Healthcare methods and procedures. In addition, numerous reports to Swedish HSAN (Medical Responsibility Board) have shown a high rate of information and communication deficiencies in Healthcare has a direct or indirect cause of incidents, injuries and deaths. Despite numerous of new sophisticated tools for information management in recent years, e.g., tools such as Electronic Health Records (EHR) and Clinical Decision Support Systems (CDSS), the threats to Patient Safety have not been redeemed. Rather to the contrary. Underlying reasons for this paradox are twofold. Firstly, advancements in diagnosing techniques have given rise to increasing volumes of data at the same time as the number of patients has increased due to demographic changes and advancements in treatments. Secondly, the information processing systems are far from aligned to related workflow processes. In short, we do not at present have interoperability in our Healthcare systems. In this doctoral dissertation, we present an in-depth analysis of two different “HSAN-typical” cases, where Patient Safety was jeopardized by incomplete information flows and/or information breakdowns. The cases are mirroring the apprehension of Simplicity, that is, Occam´s Razor of Diagnostic Parsimony. A well-known protocol used in Healthcare and implemented in most (knowledge based) CDSS. This rule of thumb is the foundation for the well-known adage: “when you hear hoof beats, think horses, not zebras”. Hickam´s Dictum is one well known objection to the simplifications of Occam´s Razor stating "Patients can have as many diseases as they damn well please". Of course, this Dictum is harder to implement effectively! In the thesis we suggest a visualization tool Visual Incidence Anamneses (VIA) to provide middle out compromise between Ockham and Hickam but providing means to increase Patient Safety. The findings of our Study for the thesis have resulted in a number of Aspects and Principles as well as Core-principles for future CDSS design, That is, tools and methodologies that will support designing and validating Interoperability of Healthcare systems across patient-centric workflows. The VIA tool should be used as the initiating point in a patient (individual) centered workflow, quickly visualizing vital information such as symptoms, incidents and diagnoses, occurring earlier in the medical history, at different times, to ground further vital decisions on. The visualization will enable analysis of timelines and earlier diagnoses of the patient, using visually salient nodes for visualization of causalities in context. Furthermore, support for customization of the tool to the views of stakeholders, members of healthcare teams and empowerments of the patient, is crucial.

Healthcare in the US continues to suffer from the poor data quality practices processes that would ensure accuracy of patient health care records and information. A lack of current scholarly research on best practices in data quality and records management has failed to identify potential flaws within the relatively new electronic health records environment that affect not only patient safety but also cost, reimbursements, services, and most importantly, patient safety. The focus of this study was to current best practices using a panel of 25 health care industry data quality experts. The conceptual lens was developed from the International Monetary Fund's Data Quality Management model. The key research question asked how practices contribute to identifying improvements healthcare data, data quality, and integrity. The study consisted of 3 Delphi rounds. Each round was analyzed to identify consensus on proposed data quality strategies from previous rounds that met or exceeded the acceptance threshold to construct subsequent round questions. The 2 best practices identified to improve data collection were user training and clear processes. One significant and unanticipated finding was that the previous gold standard practices have become outdated with technological advances, leading to a higher potential for flawed or inaccurate patient healthcare data. There is an urgent need for health care leaders to maintain heightened awareness of the need to continually evaluate data collection and management policies, particularly as technology advances such as artificial intelligence matures. Developing national standards to address accurate and timely management of patient care data is critical for appropriate health care delivery decisions by health care providers.

An empirical investigation of the security flaws and features of an in-use modern electronic health record system is performed. The investigation was carried out using dynamic analysis, manual testing and interviews with developers. The results indicate that in-use electronic health record systems suffer from serious authentication flaws, arising from the interaction of many different proprietary systems. The authentication problems are so severe that gaining access to any user’s computer on the hospital intranet would compromise a large database of patient medical records, including radiological data regarding the patients. Common web vulnerabilities were also present, such as injections and incorrectly configured HTTP security headers. These vulnerabilities were heavily mitigated by the use of libraries for constructing web interfaces.
En empirisk undersökning av säkerheten inom ett modernt elektroniskt patientjournal-system har utförts. Undersökningen genomfördes med hjälp av dynamisk analys, manuell testning och intervjuer med utvecklarna. Resultatet indikerar att system för elektroniska patientjournaler har stora brister inom autentisering, vilka uppstår p.g.a. att flera olika kommersiella system måste samarbeta. Problemen är så allvarliga att med tillgång till en enda dator på intranätet kan en stor databas med patientdata äventyras, inklusive radiologisk data gällande patienterna. Vanliga websårbarheter fanns också, så som injektioner av skript och inkorrekt konfigurerade HTTP säkerhetsheaders. Dessa sårbarheter mitigerades starkt genom användandet av bibliotek för webinterface.