Rozprawy doktorskie na temat „Integrated healthcare systems”

This study explores how managers are coping within a changing public healthcare service context and how the role of service managers and the nature of Management Development are being transformed. With the public healthcare sector in the UK facing complex challenges including financial constraint and increasing service demand, it is inevitable that collaborative partnership working and service integration are viewed as a means of addressing such challenges. Using the views and experiences of service managers from Scottish Community Health Care Partnership cases, the study highlights the experiences of managers in relation to partnership working and service integration and explores the potential implications of this for managerial learning, training and development. The research evidence establishes the importance of changing roles, responsibilities and relationships for managers in a changing healthcare service environment and takes on board a Service-Dominant approach and propositions from New Public Governance theory to explain these and to address attendant issues. Specifically, the challenges surrounding the learning, training and development of managers in an increasingly integrated services environment are explored and reconceptualised through a Services-as-Systems approach. The outcomes of this study allow for a better understanding of the changing nature of work that managers do and attempts to reframe Management Development in such a context for the future.

Managed care became the dominant model for moderating healthcare costs in the 1990's. The later half of this past decade witnessed early signs of a return to escalating premiums. Providers and consumers have reacted negatively to perceptions of health plan micro-management and restriction of choice.

Advanced information technologies promise a massive influx of individual-specific medical data. These rich sources offer great potential for an increased understanding of disease mechanisms and for providing evidence-based and personalized clinical decision support. However, the size, complexity, and biases of the data pose new challenges, which make it difficult to transform the data to useful and actionable knowledge using conventional statistical analysis. The so-called “Big Data” era has created an emerging and urgent need for scalable, computer-based data mining methods that can turn data into useful, personalized decision support knowledge in a flexible, cost-effective, and productive way. The goal of my Ph.D. research is to address some key challenges in current clinical deci-sion support, including (1) the lack of a flexible, evidence-based, and personalized data mining tool, (2) the need for interactive interfaces and visualization to deliver the decision support knowledge in an accurate and effective way, (3) the ability to generate temporal rules based on patient-centric chronological events, and (4) the need for quantitative and progressive clinical predictions to investigate the causality of targeted clinical outcomes. The problem statement of this dissertation is that the size, complexity, and biases of the current clinical data make it very difficult for current informatics technologies to extract individual-specific knowledge for clinical decision support. This dissertation addresses these challenges with four overall specific aims: Evidence-Based and Personalized Decision Support: To develop clinical decision support systems that can generate evidence-based rules based on personalized clinical conditions. The systems should also show flexibility by using data from different clinical settings. Interactive Knowledge Delivery: To develop an interactive graphical user interface that expedites the delivery of discovered decision support knowledge and to propose a new visualiza-tion technique to improve the accuracy and efficiency of knowledge search. Temporal Knowledge Discovery: To improve conventional rule mining techniques for the discovery of relationships among temporal clinical events and to use case-based reasoning to evaluate the quality of discovered rules. Clinical Casual Analysis: To expand temporal rules with casual and time-after-cause analyses to provide progressive clinical prognostications without prediction time constraints. The research of this dissertation was conducted with frequent collaboration with Children’s Healthcare of Atlanta, Emory Hospital, and Georgia Institute of Technology. It resulted in the development and adoption of concrete application deliverables in different medical settings, including: the neuroARM system in pediatric neuropsychology, the PHARM system in predictive health, and the icuARM, icuARM-II, and icuARM-KM systems in intensive care. The case studies for the evaluation of these systems and the discovered knowledge demonstrate the scope of this research and its potential for future evidence-based and personalized clinical decision support.

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, System Design and Management Program, 2018.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 64-66).
The Healthcare industry, just like any industry, is constantly racing to stay abreast with pace of technological innovations, especially at such a time where the industry is experiencing a strain on the global healthcare infrastructure. Specifically, the evolution of record management systems in the healthcare system has taken a slow and gradual transformation with each stage of transformation carrying over certain aspects and functions of previous stages. A survey of record management practices reveals that record management begun with paper-based records that have since partially been replaced with centralized Electronic Health Records (EHR). With the advent of Electronic Health Records enabled by distributed ledgers, we continue to see the inclusion of traditional paper-based functions beyond centralized EHR functions. Electronic data sharing in the healthcare ecosystem is constrained by interoperability challenges with different providers choosing to implement systems that respond to increasing their productivity. Prioritizing a patient-focused strategy during implementation of EHRs forces providers to implement systems that are more interoperable. A system engineering approach was adopted to guide the development and valuation of candidate architectures from Stakeholder analysis to concept generation and enumeration. Nine (9) key design decisions were selected with their combinations yielding 512 feasible hybrid architectures. In this paper, we proposed a hybrid EHR solution combining distributed ledger technologies and Internet of Medical Things, which contributes towards providing value-based healthcare. Leveraging properties of distributed ledgers and IoMT, the hybrid solution interconnects various data sources for health records to provide real-time record creation and monitoring whilst enabling data sharing and management in a secure manner.
by Paula Ingabire.
S.M. in Engineering and Management

La structuration territoriale des soins primaires peut être définie comme un processus de transformation évolutif et stratégique visant à réorganiser et renforcer l'organisation des soins et services de santé de première ligne. Ce processus consiste à passer d'un modèle traditionnel d'activité isolée à un modèle d'organisation territoriale plus intégré et coopératif entre professionnels, conduisant le secteur des soins primaires à se saisir d'enjeux de santé publique territoriaux. La gestion des situations sanitaires exceptionnelles constitue l'un de ces enjeux. Ce travail de thèse a pour objectif d'étudier le lien entre la structuration territoriale des soins primaires et la capacité de ce secteur à répondre aux situations sanitaires exceptionnelles, en s'appuyant sur l'exemple de l'épidémie de COVID-19.Le premier volet de la thèse présente une étude mixte visant à mieux comprendre le concept de structuration territoriale des soins primaires et à en proposer une typologie en France métropolitaine sur les territoires de vie-santé. La partie qualitative, réalisée au sein de 7 territoires, a permis d'identifier des facteurs clefs de cette structuration. A partir de ces facteurs, la partie quantitative a conduit, au moyen d'une classification hiérarchique sur composantes principales, à définir 4 types de territoires de vie-santé : des territoires peu ou pas structurés, des territoires à potentiel de structuration, des territoires en voie de structuration et des territoires déjà structurés abritant une communauté professionnelle territoriale de santé (CPTS).Le deuxième travail de la thèse a consisté à utiliser cette typologie dans une étude épidémiologique transversale portant sur l'évolution de l'activité des médecins généralistes lors de la première vague du COVID-19 en 2020. Cette étude a montré que les territoires bien structurés ont permis aux médecins de mieux s'adapter à la pandémie par un recours accru à la téléconsultation. Les résultats ont ainsi mis en évidence un lien significatif entre le niveau de structuration territoriale des soins primaires et la capacité d'adaptation des médecins généralistes.Le troisième volet s'est intéressé aux établissements d'hébergement pour personnes âgées dépendantes (EHPAD) et à leur adaptation à la crise en fonction de la structuration territoriale des soins primaires. En évaluant plusieurs catégories d'EHPAD, l'étude a montré que ceux situés dans des zones où les soins primaires étaient bien structurés présentaient une meilleure capacité de réponse face à la crise, avec moins de recours à l'hospitalisation et une mortalité plus faible. Cela souligne l'importance de la coopération entre les soins primaires et le secteur médico-social pour renforcer la résilience territoriale.La structuration territoriale des soins primaires apparaît comme un levier important pour améliorer la réponse aux crises sanitaires. Ce travail a montré que les territoires dotés d'une organisation des soins primaires structurée étaient mieux à même de maintenir la continuité des soins et de collaborer avec les autres secteurs de santé. Les perspectives pour l'avenir incluent le renforcement de cette structuration, catalyseur de la responsabilité populationnelle des acteurs, afin de mieux préparer le système de santé français aux futures crises
The territorial structuring of primary care can be defined as an evolving and strategic transformation process aimed at reorganising and strengthening the organisation of first-line healthcare services. This process involves moving from a traditional model of isolated practice to a more integrated and cooperative territorial organisation among professionals, leading the primary care sector to address territorial public health challenges. The management of exceptional health situations is one of these challenges. The main objective of this thesis is to study the relationship between the territorial structuring of primary care and the sector's capacity to respond to exceptional health situations, using the COVID-19 epidemic as an example.The first part of the thesis presents a mixed-methods study designed to better understand the concept of territorial structuring of primary care and to propose a typology for mainland France at the level of life-health territories. The qualitative component, conducted in seven territories, helped identify key factors of this structuring. Based on these factors, the quantitative component used a hierarchical clustering on principal components approach to define four types of life-health territories: territories that are poorly or not structured, territories with potential for structuring, territories in the process of structuring, and fully structured territories hosting a health territorial and professional community (HTPC).The second part of the thesis used this typology in a cross-sectional epidemiological study focused on changes in the activity of general practitioners during the first wave of COVID-19 in 2020. This study showed that well-structured territories allowed physicians to better adapt to the pandemic, notably through increased use of teleconsultation. The results highlighted a significant link between the level of territorial structuring of primary care and the adaptability of general practitioners.The third part focused on nursing homes and their adaptation to the crisis based on the territorial structuring of primary care. By evaluating several categories of nursing homes, the study demonstrated that those located in areas with well-structured primary care exhibited a better capacity to respond to the crisis, with fewer hospital admissions and lower mortality. This underscores the importance of cooperation between primary care and the medico-social sector to enhance territorial resilience.The territorial structuring of primary care appears to be an important lever for improving responses to health crises. This work has shown that territories with structured primary care organisations were better able to maintain continuity of care and collaborate with other health sectors. Future perspectives include strengthening this structuring, which serves as a catalyst for population-level responsibility among stakeholders, to better prepare the French healthcare system for future crises

Thesis (MTech (Information Technology))--Cape Peninsula University of Technology, 2016.
The delivery of healthcare services should be of a high standard for everyone. For people in the location of Mantunzeleni this is not the case as there are still challenges that they go through in order to gain access to sufficient healthcare services. The location consists of four villages and the other nine which surround the four, in total this makes thirteen villages that are served by one clinic. These villages are divided by forest, rivers and mountains, people have to cross these and walk long distances to get to the clinic. Gaining access to basic healthcare services in rural areas has never been easy, hence this study seeks to understand the role telehealth could play to help improve the situation. It has been reported in the literature that telehealth has potential to address some of the problems experienced by healthcare service providers located in the rural areas. Research questions were posed to address the problem of limited access to healthcare services of under-served communities in rural areas. The study adopted an interpretive approach to understand how the people using healthcare services in the setting attach meaning to their experiences of the healthcare service. The study therefore seeks to understand how telehealth could improve healthcare service delivery through the participants’ views, perceptions and experiences. The research strategy for this study is a single case study without attempting to generalise the findings. Qualitative data was gathered using unstructured interviews, observations and co-design methods. The current state of telehealth and challenges of healthcare services in rural under-served communities was established through a review of relevant literature. It was important to actively involve the respondents in the research process for them to feel a sense of ownership. Data was analysed using a thematic analysis. The findings revealed the challenges currently hampering the delivery of healthcare in the research setting include poor infrastructure, high cost, the shortage of medical professionals, travelling distance, time management and lack of communication about the services. It was also revealed the role telehealth could play a role to improve access to healthcare and the findings indicate that the nurses feel that extending the healthcare service to include alternative access methods to health information, education and expertise could lead to a sense of appreciation, knowledge gain, dealing with distance problems and improved referrals, cost saving to improve healthcare service delivery.

Health service organizations are increasingly required to deliver quality healthcare services without increasing costs. The adoption of health information technologies can assist these organizations to deliver a quality service; however, this again exposes the health information to threats. The protection of personal health information is critical to ensure the privacy of patients in the care of health service organizations. Therefore both quality and information security are of importance in healthcare. Organisations commonly use management system standards to assist them to improve a particular function (e.g. quality or security) through structured organizational processes to establish, maintain and optimise a management system for the particular function. In the healthcare sector, the ISO 9001, ISO 9004 and IWA 1 standards may be used for the purpose of improving quality management through the establishment of a quality management system. Similarly, the ISO 27001 and ISO 27799 standards may be used to improve information security management through the establishment of an information security management system. However, the concurrent implementation of multiple standards brings confusion and complexity within organisations. A possible solution to the confusion is to introduce an integrated management system that addresses the requirements of multiple management systems. In this research, various standards relevant to the establishment of management systems for quality and security are studied. Additionally, literature on integrated management systems is reviewed to determine a possible approach to establishing an IMS for quality and information security in healthcare. It will be shown that the quality management and information security management standards contain commonalities that an integration approach can be based on. A detailed investigation of these commonalities is done in order to present the final proposal of the IMSQS, the Integrated Management System for Quality and Information Security in healthcare.

This thesis aimed to investigate the determinants of system satisfaction and the intention to systematically integrate a system from a continuous use perspective, where system use is mandatory. For this purpose, two identical questionnaires were distributed to collect data, 15 months apart. Respondents taking part in this study are healthcare multi-professionals who pertain to a work-group at an intensive care unit, at a large Swedish hospital. To evaluate the questionnaire data a research model was conceptualized, grounded in prior information system continuance research. It is also significantly influenced by the UMISC metamodel, conceptualized and suggested by Hadji & Degoulet (2016). The collected data was then analyzed using a two-stage analysis where one aspect was comparative, i.e., a comparison of the data between the two questionnaires, and the other was explorative, wherein research model constructs and their relations were evaluated. This analysis provided significant insight into the determinants of system satisfaction. However, regarding the determinants of the intention to systematically integrate as well as the research model itself, neither could be validated in this study. Nevertheless, these results allowed for a modified model to be conceptualized, with potentially promising results.

Mestrado em Gestão de Sistemas de Informação
No cenário de transformação digital em que estão inseridos todos os setores de atividade, para melhorar a eficiência, a produtividade e reduzir o tempo e os custos, é necessário investir em novas tecnologias. Novas tecnologias como Internet of Things (IoT) e Blockchain são desenvolvidas para melhorar a eficiência de processamento, a criação de oportunidades de negócios, a regulamentação de requisitos, a segurança e transparência e descentralização de informações, e provavelmente serão as próximas tecnologias disruptivas que transformaram os diversos setores de atividade. Por sua vez, o setor saúde tem enfrentado dificuldades com o surgimento de novas doenças e precisa se transformar e se reinventar para manter sua legitimidade e continuar cumprindo suas obrigações para com os cidadãos. A implementação de novas tecnologias acaba sendo uma das abordagens mais eficazes para aumentar a eficiência, segurança, gerenciamento, análise de big data e performance dos dados. Devido a isso, este projeto propõe um modelo de framework Blockchain e IOT aplicada a saúde. A implementação engloba a criação de um aplicativo (i.e., pacientes) e um site (i.e., médicos, hospitais, farmácias, saúde publica), os dados partilhados pelos usuários são armazenados no blockchain conectado ao aplicativo e o acesso ao Blockchain é liberado por smartcontracts. O objetivo do modelo proposto é que os dados sejam descentralizados e possibilita o acesso a todos os conectados ao blockchain. E para não infringir a proteção dos dados pessoais dos pacientes, foi tomado o cuidado de que o usuário paciente seja o “proprietário” de todos os seus dados e compartilhe-os com qualquer entidade de saúde que deseja. Para atingir os objetivos mencionados, foi definida uma metodologia de validação por conceito do modelo proposto. A validação do conceito do modelo foi dividida em cinco etapas, seguida da análise qualitativa das entrevistas semiestruturadas realizadas com pacientes, médicos e gestores de saúde. Como resultado da validação por conceito foi observado que a opinião de todos os entrevistados é que a implementação do modelo proposto é vantajosa e poderá contribuir com avanços no setor saúde. Portanto, uma vez que médicos e hospitais tenham acesso a mais dados de saúde dos pacientes, esses dados podem colaborar para um diagnóstico mais preciso e o ecossistema da saúde obtém avanços tecnológicos que contribuem para uma melhor gestão dos dados e combate as novas doenças.
In the digital transformation scenario in which all sectors of activity are inserted, to improve efficiency, productivity and reduce time and costs, it is necessary to invest in new technologies. New technologies such as Internet of Things (IoT) and Blockchain are being developed to improve processing efficiency, the creation of business opportunities, requirements regulation, security and transparency and information decentralization, and are likely to be the next disruptive technologies that have transformed the various sectors of activity. In turn, the health sector has confronted difficulties with the emergence of new diseases and needs to transform and reinvent itself in order to maintain its legitimacy and continue to fulfill its obligations to citizens. The implementation of new technologies is one of the most effective approaches to increase efficiency, security, management, big data analysis and data performance. Because of this, this project proposes a Blockchain and IOT framework model applied to health. The implementation includes the creation of an application (ie, patients) and a website (ie, doctors, hospitals, pharmacies, public health), the data shared by users is stored on the blockchain connected to the application and access to the Blockchain is released by smart contracts. The aim of the suggested model is that the data is decentralized and allows access to all those connected to the blockchain. And in order not to infringe on the protection of patients' personal data, care has been taken that the patient user is the “owner” of all his data and shares it with any health entity he wishes. To achieve the objectives was applied a validation methodology by concept of the proposed model. The validation of the model concept was divided into five stages, followed by a qualitative analysis of the semi-structured interviews conducted with patients, doctors and health managers. As a result of the concept validation, it was observed that the opinion of all interviewees is that the implementation of the proposed model is advantageous and may contribute to advances in the health ecosystem. Therefore, once doctors and hospitals have access to more patients health data, these data can collaborate for a more accurate diagnosis and the health ecosystem obtains technological advances that contribute to better data management and to fight new diseases.
info:eu-repo/semantics/publishedVersion

The overall aim of the research was to produce a validated framework for a Malaysian integrated and distributed telemedicine system. The framework was constructed so that it was capable of being useful in retrieving and storing a patient’s lifetime health record continuously and seamlessly during the downtime of the computer system and the unavailability of a landline telecommunication network. The research methodology suitable for this research was identified including the verification and validation strategies. A case study approach was selected for facilitating the processes and development of this research. The empirical data regarding the Malaysian health system and telemedicine context were gathered through a case study carried out at the Ministry of Health Malaysia (MOHM). The telemedicine approach in other countries was also analysed through a literature review and was compared and contrasted with that in the Malaysian context. A critical appraisal of the collated data resulted in the development of the proposed framework (MyTel) — a flexible telemedicine framework for the continuous upkeep of patients’ lifetime health records. Further data were collected through another case study (by way of a structured interview in the outpatient clinics/departments of MOHM) for developing and proposing a lifetime health record (LHR) dataset for supporting the implementation of the MyTel framework. The LHR dataset was developed after having conducted a critical analysis of the findings of the clinical consultation workflow and the usage of patients’ demographic and clinical records in the outpatient clinics. At the end of the analysis, the LHR components, LHR structures and LHR messages were created and proposed. A common LHR dataset may assist in making the proposed framework more flexible and interoperable. The first draft of the framework was validated in the three divisions of MOHM that were involved directly in the development of the National Health ICT project. The division includes the Telehealth Division, Public and Family Health Division and Planning and Development Division. The three divisions are directly involved in managing and developing the telehealth application, the teleprimary care application and the total hospital information system respectively. The feedback and responses from the validation process were analysed. The observations and suggestions made and experiences gained advocated that some modifications were essential for making the MyTel framework more functional, resulting in a revised/final framework. The proposed framework may assist in achieving continual access to a patient’s lifetime health record and for the provision of seamless and continuous care. The lifetime health record, which correlates each episode of care of an individual into a continuous health record, is the central key to delivery of the Malaysian integrated telehealth application. The important consideration, however, is that the lifetime health record should contain not only longitudinal health summary information but also the possibility of on-line retrieval of all of the patient’s health history whenever required, even during the computer system’s downtime and the unavailability of the landline telecommunication network.

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, System Design and Management Program, 2018.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 45-47).
The US healthcare system is looked at from the point of view of various stakeholders and how its current structure has emerged over the years. With the shifting demographics, change in disease mix, ICT revolution and other factors at play, the system is in a state of flux. Sensor technology on the other hand has also progressed over the years to reach a point where low-cost mass-produced smart sensors are becoming omnipresent. A variety of such sensors are now available, and new ones are being developed for specific needs, like for continuous health monitoring systems. New wireless sensing technologies are redefining the care services, processes and customer expectations. This is especially true for chronic disease management and eldercare. We develop a view point to understand at a broad level how the US healthcare system is currently evolving and what role could new technologies, like wireless sensing, play in shaping its near future. These new technologies are slowly gaining foothold in the market and could possibly reach a point of inflection soon where the population starts to adopt them in masses. By creating a new mental model of how various parts in the system interact with each other, we try and develop an understanding of which factors might affect the speed of adoption of these new technologies into the system.
by Kanishka Nohria.
S.M. in Engineering and Management

Healthcare problems are complex; they exhibit both detail and dynamic complexity. It has been argued that Discrete Event Simulation (DES), with its ability to capture detail, is ideal for problems exhibiting this type of complexity. On the other hand, System Dynamics (SD) with its focus on feedback and nonlinear relationships lends itself naturally to comprehend dynamic complexity. Although these modelling paradigms provide valuable insights, neither of them are proficient in capturing both detail and dynamic complexity to the same extent. It has been argued in literature that a hybrid approach, wherein SD and DES are integrated symbiotically, will provide more realistic picture of complex systems with fewer assumptions and less complexity. In spite of wide recognition of healthcare as a complex multi- dimensional system, there has not been any reported study which utilises hybrid simulation. This could be attributed to the fact that due to fundamental differences, the mixing of methodologies is quite challenging. In order to overcome these challenges a generic theoretical framework for hybrid simulation is required. However, there is presently no such generic framework which provides guidance about integration of SD and DES to form hybrid models. This research has attempted to provide such a framework for hybrid simulation which can be utilised in healthcare domain. On the basis of knowledge induced from literature, three requirements for the generic framework have been established. It is argued that the framework for hybrid simulation should be able to provide answers to Why (why hybrid simulation is required), What (what information is exchanged between SD and DES models) and How (how SD and DES models are going to interact with each other over the time to exchange information) within the context of implementation of hybrid simulation to different problem scenarios. In order to meet these requirements, a three-phase generic framework for hybrid simulation has been proposed. Each phase of the framework is mapped to an established requirement and provides guidelines for addressing that requirement. The proposed framework is then evaluated theoretically based on its ability to meet these requirements by using multiple cases, and accordingly modified. It is further evaluated empirically with a single case study comprising of Accident and Emergency department of a London district general hospital. The purpose of this empirical evaluation is to identify the limitations of the framework with regard to the implementation of hybrid models. It is realised during implementation that the modified framework has certain limitations pertaining to the exchange of information between SD and DES models. These limitations are reflected upon and addressed in the final framework. The main contribution of this thesis is the generic framework for hybrid simulation which has been applied within healthcare context. Through an extensive review of existing literature in hybrid simulation, the thesis has also contributed to knowledge in multi-method approaches. A further contribution is that this research has attempted to quantify the impact of intangible benefits of information systems into tangible business process improvements. It is expected that this work will encourage those engaged in simulation (e.g., researchers, practitioners, decision makers) to realise the potential of cross-fertilisation of the two simulation paradigms.

Abstract The purpose of this study is to investigate how big data solutions in the Swedish healthcare system can generate a revenue. As technology continues to evolve, the use of big data is beginning to transform processes in many different industries, making them more efficient and effective. The opportunities presented by big data have been researched to a large extent in commercial fields, however, research in the use of big data in healthcare is scarce and this is particularly true in the case of Sweden. Furthermore, there is a lack in research that explores the interface between big data, healthcare and revenue models. The interface between these three fields of research is important as innovation and the integration of big data in healthcare could be affected by the ability of companies to generate a revenue from developing such innovations or solutions. Thus, this thesis aims to fill this gap in research and contribute to the limited body of knowledge that exists on this topic. The study conducted in this thesis was done via qualitative methods, in which a literature search was done and interviews were conducted with individuals who hold managerial positions at Region Västerbotten. The purpose of conducting these interviews was to establish a better understanding of the Swedish healthcare system and how its structure has influenced the use, or lack thereof, of big data in the healthcare delivery process, as well as, how this structure enables the generation of revenue through big data solutions. The data collected was analysed using the grounded theory approach which includes the coding and thematising of the empirical data in order to identify the key areas of discussion. The findings revealed that the current state of the Swedish healthcare system does not present an environment in which big data solutions that have been developed for the system can thrive and generate a revenue. However, if action is taken to make some changes to the current state of the system, then revenue generation may be possible in the future. The findings from the data also identified key barriers that need to be overcome in order to increase the integration of big data into the healthcare system. These barriers included the (i) lack of big data knowledge and expertise, (ii) data protection regulations, (iii) national budget allocation and the (iv) lack of structured data. Through collaborative work between actors in both the public and private sectors, these barriers can be overcome and Sweden could be on its way to transforming its healthcare system with the use of big data solutions, thus, improving the quality of care provided to its citizens. Key words: big data, healthcare, Swedish healthcare system, AI, revenue models, data-driven revenue models

Introduction The Saudi healthcare system was established in 1926, and consisted of three levels of service: (i) primary; (ii) secondary; and (iii) tertiary healthcare that are currently available through the Ministry of Health (MOH) network. The primary healthcare (PHC) system serves as a gatekeeper to secondary and tertiary healthcare. The referral system, or the process between primary and secondary care, is essential in the management of healthcare systems, as well as chronic non-communicable diseases (NCD). The World Health Organization (WHO) Global NCD Action Plan 2013-2020 was aimed to … strengthen and organise services … access and referral systems around close-to-user and people-centred networks of primary health care are fully integrated with the secondary and tertiary care level of the healthcare delivery system, including quality rehabilitation, comprehensive palliative care and specialised ambulatory and inpatient care facilities. In Saudi Arabia, the demand for secondary care in a hospital has been increasing through high referral rates and emergency department (ED) non-urgent case visits. In the recent National Transformation Program (NTP), Vision 2030, the reform and restructure of PHCs was a priority, that is, to ease access to healthcare, to reduce the inefficient use of healthcare services, and to improve the quality of PHCs. Some of the program’s objectives were to improve patient satisfaction of PHCs and to reduce the number of inappropriate referrals by PHCs. Therefore, three aims of this PhD research are: (i) to assess patient satisfaction, experience of PHCs and care coordination in Saudi Arabia; (ii) to evaluate the attitudes and decision-making of physicians in regard to referral system; and (iii) to identify conceivable interventions/systems of referral by targeting NCD in Saudi Arabia. Method A mixed method approach is used to answer three research questions: (i) How do patients rate the quality of care received in PHCs by measuring their satisfaction and experience?; (ii) How do physicians make decisions on referrals to secondary care?; and (iii) How do physicians evaluate the referral system? To answer the first research question, two phases were implemented, involving 157 patients recruited through the Sharik initiative from 10 regions of 13 regions of Saudi Arabia. Phase 1 applied a cross-sectional study by using a Patient Satisfaction Questionnaire (PSQ-18) (Arabic) to measure the overall satisfaction of PHCs and to assess its correlation to sociodemographic characteristics of patients. Phase 2 involved a cross-sectional study by using the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) (Arabic) to measure the overall experience ratings and assess its correlation to sociodemographic characteristics of patients. In the Research Question 2, a cross-sectional study, the Ambulatory Sentinel Practice Network (ASPN) tool was incorporated to explore and assess the attitudes and decisions made by physicians regarding referrals in PHCs. A sample of 68 physicians were recruited from 15 PHCs. To answer Research Question 3, 19 physicians were recruited from 15 PHCs for inclusion in a semi-structured interview using the Referral System Assessment and Monitoring (RSAM) tool to evaluate the referral system from their perspective and to synthesise their views on seven successful factors for integrated care from a total of 10 factors. Results Research Question 1: Phase 1 (Quantitative) PSQ-18 consisted of 18 items constituting seven domains: (i) general satisfaction; (ii) technical quality; (iii) financial aspects; (iv) interpersonal manner; (v) communication; (vi) time spent with the doctor; and (vii) accessibility and convenience. The relationship between sociodemographic factors (age, gender, income, education and marital status, health status and the type of PHCs) and seven domains of PSQ-18 and total satisfaction (from seven domains ranging from 18-90) were assessed in bivariate tests and multiple linear regressions. In the bivariate analysis, age, gender, education. marital status, and health status were associated with the some of the domains of satisfaction. Age was associated with financial aspects domain with a p value of p=0.040. Gender was associated with two domains interpersonal manner and communication with p value of p=0.024 and p=0.045 respectively. Education was associated two domains technical quality and financial aspects with p values of p=0.012 and p=0.003 respectively. Marital status was only associated with communication domain with a p value of p=0.012. The health status was associated with interpersonal manner with a p value of p=0.018. In the multiple linear regression, none of the sociodemographic factors predicted general satisfaction, time spent with doctor, and accessibility and convenience domains. However, education, marital status and health status predicted technical quality, interpersonal manners, communication and total satisfaction. Marital status was a strong predictor of technical quality, communication and total satisfaction. Research Question 1: Phase 2 (Quantitative) Using CG-CAHPS, the relationship between a patient’s sociodemographic factors (age, gender, income, education, marital status, health status and the type of PHCs), the quality of physician/patient communication, care coordination and overall ratings in PHCs were assessed. Sociodemographic factors were not associated with overall ratings except for the type of PHCs. Communication and care coordination items were associated with overall ratings. In the multiple linear regression, the model revealed that a total of 81% of the overall rating (satisfaction) could be attributed to the predictors included. The communication domain had the highest number of predictors on the overall ratings. The highest predictor of the overall rating was physicians answering their patients’ questions, followed by time spent with the physician, type of PHC, and the ability of the physician to listen carefully, to explain things clearly and to show respect. The weakest predictors were from the care coordination domain followed by the healthcare provider’s and physician’s knowledge of the patient’s medical history. Research Question 2: Phase 3 (Quantitative) A total of 68 physicians participated in this study from 15 PHCs from five health regions in Riyadh city. Approximately 39.7% of patients received two or more referrals in their visits. Over 51% of patients’ reasons for visiting PHCs were to obtain a referral. More than half of the physicians (55.9%) stated they referred patients who needed advice on diagnosis and treatment, followed by direct surgical management/treatment and a need for multidisciplinary care. Abdominal pain was the highest condition being referred to by physicians (5.8%). Around 32.2% of physicians considered the quality of feedback as ‘very important’ when selecting a clinic or hospital. One quarter of physicians (25%) viewed the technical capacity of the consultative centre to be ‘very important’. A small percentage (11.8%) of physicians viewed patient requests to present at a clinic as a ‘very important’ aspect while 44.1% of physicians viewed it as ‘somewhat important’. Research Question 3: Phase 4 (Qualitative) Nineteen physicians from 15 PHCs were interviewed in this study. In synthesising the interviews, seven of the 10 principles of successful integrated care were used because they are feasible in the current Saudi healthcare system for referrals: (i) comprehensive services across the care continuum; (ii) patient focus; (iii) geographic coverage and rostering; (iv) standardised care delivery through inter-professional teams; (v) performance management; (vi) information systems; and (vii) organisational culture and leadership. There were major problems with each aspect of the information system. Physicians reported that the feedback procedure was almost non-existent. Although referral protocols and guidelines existed, these were not available in all PHCs. The system relied on accurate knowledge about the referral network, but directories of hospitals in the network were not available in all PHCs. Some physicians were dissatisfied about their patients’ role in the referral letter that was generated only ‘Upon Patient’s Request’. Data of the referrals were collected and analysed in most PHCs. However, evaluation reports were not shared with PHCs. Conclusion Using the PSQ-18 questionnaire, the results confirmed that sociodemographic factors affect the satisfaction score of PHCs in the bivariate and multiple linear regression. However, sociodemographic factors do not play any role in the overall rating when using the patient experience (CG-CAHPS) questionnaire. Furthermore, physician/patient communication and the type of PHC is fundamental in predicting overall ratings of PHCs in the bivariate and multiple linear regression. With regard to physicians making decisions on referrals, the study showed different ‘medical’ and ‘non-medical’ reasons for referrals in PHCs. In addition, there were system-related reasons for referrals that could be emphasised, since the availability of such services in PHCs plays a major role in referrals. In evaluating the referral system, results suggested that improvement to the referral system is necessary, in particular, appointments to support efficient time management, provision of an up-to-date directory of hospitals, training for physicians from PHCs and an increased awareness of the significance of feedback from hospitals.

Numerosi articoli di ricerca suggeriscono che dedicarsi all’attività fisica promuove un impatto positivo sulla salute e sul benessere in età avanzata. Il passaggio al regime domiciliare è noto in letteratura per essere un momento di elevata discontinuità nell'assistenza a causa della scarsa aderenza e motivazione del paziente, scarsa comprensione dei benefici delle cure riabilitative, scarsa predisposizione al cambiamento nello stile di vita. Efficaci interventi di riabilitazione implementati in uno scenario domiciliare possono fornire una terapia efficace per la popolazione anziana, portando di conseguenza a miglioramenti del sistema tra cui una riduzione dei costi e un uso più appropriato delle risorse.Sebbene promettente, la gestione della cronicità con tecnologie innovative dell'informazione e della comunicazione (ICT) non ha ancora raggiunto un livello sufficiente di specializzazione, qualità e robustezza. Inoltre, le soluzioni ICT sono spesso viste come "elementi isolati" nella gestione del paziente piuttosto che essere principalmente interventi di supporto al cambiamento, nell'organizzazione e nei paradigmi di cura. Il progetto regionale in cui è inserito il dottorato ha l'obiettivo di separare il divario tra soluzioni dell’Information Technology e della riabilitazione domestica. La soluzione proposta intende rispondere a questa esigenza creando una piattaforma integrata che coinvolga pazienti, operatori sanitari, caregiver e tecnologie ICT, per pianificare ed eseguire trattamenti domiciliari individualizzati e controllati da remoto. L'obiettivo del lavoro presentato in questa dissertazione è la progettazione tecnica e implementazione di un sistema di supporto decisionale (DSS) interoperabile in grado di supportare il medico nel processo di prescrizione di un trattamento riabilitativo domiciliare a un paziente anziano. L’obiettivo che si prefigge il lavoro è di presentare al medico raccomandazioni personalizzate basate sui dati del paziente al fine di costruire una prescrizione “su misura” in base alle condizioni attuali del paziente e ai risultati desiderati. La raccomandazione fornita dal DSS deve essere basata sulle evidenze scientifiche più recenti disponibili, completamente interpretabile dalla macchina per supportare l'analisi automatica dei dati del paziente, eliminando così qualsiasi inserimento manuale ripetitivo di dati da parte del medico. In primis è stata effettuata un’analisi approfondita della letteratura, per identificare lo stato dell'arte. Inoltre, vengono brevemente analizzate le leggi e i regolamenti che devono essere seguiti per prendere in carico un paziente sfruttando soluzioni ICT. L'attività di ricerca prosegue individuando requisiti funzionali.Particolare attenzione è riservata alla scelta di aderire ai più recenti e stabili standard disponibili in sanità a diversi livelli: livello di modellazione dei dati: HL7 FHIR R4; paradigma di comunicazione: CDS Hooks versione 1.0.0; formalizzazione knowledge base: HL7 CQL versione 1.3, linee guida cliniche FHIR. La dissertazione presenta in dettaglio il progetto tecnico che ha guidato lo sviluppo del DSS. Vengono offerti i punti chiave dell'implementazione del DSS che rappresentano il contributo originale di questo lavoro e, quando possibile, viene fornito un riferimento ad un repository open source o a una porzione di codice sorgente. Inoltre, viene descritto un plug-in che arricchisce la navigazione del testo libero di una linea guida utilizzando il concetto di knowledge graph. Viene infine presentata la metodologia con la quale si intende validare il DSS nella fase sperimentale del progetto dal punto di vista tecnico, funzionale e di usabilità. Tra gli sviluppi futuri di questo lavoro citati si menziona lo sviluppo di un servizio per sollecitare automaticamente la revisione di un trattamento domiciliare analizzando i dati provenienti da sensori di monitoraggio remoto.
Numerous Research paper suggests that being physically active promotes a positive impact of on health and wellbeing in older age. Plentiful of authors agree that systematic physical exercises are capable of positively impact healthy ageing, attenuating declines in health, exerting positive cognitive and psychological effects, on the top of physical ones.The transition from hospital to home-care is known to be a time of high discontinuity in assistance due to poor adherence and patient motivation, poor understanding of benefits of rehabilitation care, poor predisposition to change in lifestyle.Effective Rehabilitation interventions deployed in a home-based scenario could provide effective therapy for elderly population, consequently leading to system improvements including decreased costs, more appropriate resource use, and avoidance of institutional placements.Although promising, the management of chronicity with innovative information and communication technologies (ICT) has not yet reached a sufficient level of specialization, quality, and robustness. Furthermore, ICT solutions are often seen as "isolated elements" in patient management rather than being primarily supportive interventions change, in the organization and in the paradigms of care.The regional project in which the PhD is inserted, has the aim to connect the bridge of ICT and home rehabilitation.The project intends to respond to this need by creating an integrated platform involving patients, healthcare professionals, caregivers, and ICT technologies, to plan and carry out individualized and remotely controlled home treatments. The goal of the work presented in this dissertation is to design and implement an interoperable, Decision Support System (DSS) that can support the physician in the process of prescribing an elder patient a home-care rehabilitation treatment.The desired outcome requires the system to present personalized recommendations based on patients’ data to make a tailored prescription on patient current condition and desired outcomes.The recommendation delivered by the DSS must be coming from the most recent Evidence Based Medicine and needs to be fully machine-interpretable in order to support automatic analysis of patient data, thus eliminating any repetitive manual data entry to the DSS by the physician. The goal has been achieved by different propaedeutic phases. A thorough literature analysis, to identify the state of the art.In addition, the laws and regulations that need to be followed to treat a patient with ICT solutions are briefly analyzed. The research activity progress by identifying functional requirements. Special attention is paid to the choice of adhering to the most recent but stable healthcare standards at different levels: data modeling level: HL7 FHIR R4; communication paradigm: CDS Hooks Version 1.0.0;knowledge base formalization: HL7 CQL Version 1.3, FHIR clinical guidelines. The dissertation presents thorough detailing of the technical design that guided the development of the DSS, stressing importance of adhering to international standard drives the discussion, with a specific focus on how to build an interoperable system that can be easily integrated in a real setting.Key points of the implementation of the DSS that represent the original contribution of this work are provided and, when possible, a reference to an open source repository code or a code snippet is supplied. In addition, a plugin is outlined, which enhances navigation of the free text of a guideline using knowledge graphs. Finally, the discussion presents the validation methodology that will be applied in the experimental phase. The validation is presented from different points of view: technical, functional and usability. Future developments of this work include a service to automatic solicit the revision of a home-care treatment by analyzing the data coming from remote monitoring sensors.

The purpose of this study is to explore performance measurement systems in the healthcare services in Malaysia. This study postulates a framework based on an analysis of the existing literature in the field and on the empirical evidence collected during fieldwork. This framework provides a useful perspective for studying performance measurement in developing countries such as Malaysia. Moreover, identification of gaps in the field enables both academics as well as practitioners to improve the existing systems, thereby creating more robust and better surveillance in the healthcare industry. The findings show that in order for systems to operate efficiently, three major components must work together, namely strategy formulation and deployment, internal control systems, and managing processes. The empirical framework developed in the study represents an amalgamation of approaches used in organisations. One of the findings is that top management commitments, people involvement, and structure to accommodate change process are the catalyst for measurement systems to work. Further analysis reveals (survey) that 80% of users are not satisfied with their measurement system. This means that there is a need for further research in the future. Performance measurement is in its embryonic stage in Malaysia as the survey reveals domains accomplishment of less than 50%. The healthcare industry is inevitably growing and the Malaysian government needs to address the importance of measuring performance in the long run. Learning from another country's experience is the best way forward. The thesis also provides a context in which performance measurement works. There are two contexts applied: healthcare industries and Malaysia. Both contextual elements are important; healthcare has special attributes that make it different from other industries, while Malaysia has unique properties that provide a fresh look at healthcare. The key to successful performance measurement is to ensure congruence in all elements of the systems: context (Malaysia and healthcare) and content (organisations where systems exist). Then integration can be accomplished.

Obesity, a condition of excess body fat, is one of the most complex problems facing health systems. Lifestyle management programs that combine diet, physical activity, and intensive behavioral therapy have been shown by research to support a degree of weight loss that produces health benefits (i.e., at least a 3-5% initial body weight). However, it has been difficult for research-developed programs to be delivered in typical practice to have a meaningful impact. Integrated research-practice partnerships that involve the coming together of academic researchers, health system administrators, and program delivery staff may help overcome this gap, especially during this transformational time in the healthcare sector. This dissertation aimed to develop an understanding of how using the integrated research-practice approach would facilitate and sustain evidence-based lifestyle management strategies across a health system to treat obesity among patients and employees. An integrated research-practice partnership with Carilion Clinic, a health system in western Virginia, served as an example for the study. From 2013-2016, the Carilion Clinic integrated research-practice partnership conducted a series of trials testing different strategies for delivering weight loss and weight loss maintenance support. An evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted to describe implementation processes and outcomes for each strategy. Lessons learned from the evaluation support the value of the integrated-research practice partnership approach as a solution for overcoming gaps in obesity care. A shared priority perspective between research and practice was identified as the powerful process for supporting facilitation and sustainability of strategies. In addition, findings from the evaluation produced evidence to inform the future development of a system for Carilion Clinic to help patients and employees lose weight and keep it off through lifestyle management.
Ph. D.

The need for donor funding has increased significantly over the last decade. Without donor funding millions of people wouldn’t be alive today. Thanks either to research finding a cure, successful treatment, funds donated for food, aid toward building infrastructure, or giving people the opportunity to further their education. Donor funding thus facilitates a better future. A literature review was conducted to give background on the health sector and how these funds were distributed, ethical clearance, different types of reporting, the role project managers pays in a project and the sustainability of projects. Expenses in different countries were evaluated by gathering data from the internet, while two international funded projects are also used to state how funders divide their line items into different categories. The empirical study used a qualitative research approach by collecting and analysing data obtained from the MDG 2010 report and other freely available data on the web. The main findings from this thesis are: *The Millennium Development Goals (MDG’s) influence donor funding as it gives donors a guide towards funding needs. Donors are also influenced by their own preferences or what poses a burden to them individually. *The different types of reporting required for funding received, delay a project and the bureaucratic structures thereof are a hindrance. *Ethical clearance plays a fundamental role in the outcome of a project, as without ethical clearance a project cannot commence. *The objectives of a project play a critical role when applying for funding. This can change the focus of a project. *Expenses differ from country to country and funders need to take this into account when giving funding to recipient countries. *Project Managers and community involvement plays a critical role in ensuring sustainability of projects. THE SUSTAINABILITY OF DONOR FUNDED PROJECTS IN THE HEALTH SECTOR *The MDG’s are not on track and aid are focus on singular goals instead of multiple goals, to ensure an overall improved result. There is a major gap between needed funds and given funds. A single injection of funds will not be the solution to our health problem; different sectors need to collaborate together as we are facing a multi-dimensional problem. Trade and reform must also form part of this aid, ensuring a sustainable progression in the life’s of people. Donor funded projects may have a sustainable future, when taking in account the abovementioned findings. With the world trend in reporting changing rapidly, cost and management accountants as well as financial accountants and project managers have to equip them to adhere to the new way of reporting, namely integrated and sustainability reporting. South Africa is way behind and needs to catch up fast if they want to stay competitive in the “global donor funding market”. The limitations in this study were that not all expenses were evaluated and only 15 countries were looked at. An indebt look was taken into Africa with the empirical review, while Asia is also combating poor health issues. Some African countries like Sierra Leone and Zimbabwe did not have sufficient data to compare with other countries. From the research conducted, the following topics were identified that require further research: *Why are most projects in Third World countries not sustainable? *What plans are put into action to ensure that the MDG goals are reached? *Investigate what works for First World countries health systems and consider how that can be applied to Third World countries to ensure that they also get the best health care available. *Do donors take into account the different costs of countries when allocating funding to that specific country? *Establishing models to evaluate the sustainability of pilot projects and normal projects. *Establishing a model on how to distribute donor funds across different needs and not only one specific need.
MCom (Management Accountancy), North-West University, Vaal Triangle Campus, 2013

Röntgenavdelningen har ett blandat flöde av patienter vilket medför att denna är en potentiell smittväg för olika sjukdomar. För att minska risken för smittspridning är det viktigt att de basala hygienrutinerna följs, dock visar studier på att följsamheten till de basala hygienrutinerna är låg. Syfte: Syftet med denna litteraturöversikt var att undersöka hur röntgensjuksköterskans följsamhet till handhygienrutiner kan förbättras. Metod: En integrativ litteraturöversikt där vetenskapliga artiklar har sökts i databaserna PubMed och CINAHL. 15 artiklar har kvalitetsgranskats, kategoriserats, analyserats och slutligen har resultatet sammanställts och en syntes skrivits. Resultat: Olika typer av interventioner, såsom utbildning, information, automatiserade observationssystem och multimodala interventioner kan vara hjälpsamma i arbetet med att förbättra följsamheten till handhygienrutinerna Slutsats: Praktisk och teoretisk utbildning, en engagerad ledning och ett klimat i kombination med god tillgång till handhygienprodukter och påminnelser om att utföra handhygien är viktiga delar i arbetet med att förbättra följsamheten till handhygienrutiner.
The radiology department has a mixed flow of patients which means that it has the potential to become a site for infection transmission. In order to reduce the risk of infection spreading it is important that the basic hand hygiene routines are followed. However, studies show that the compliance with the basic hand hygiene routines is low. Aim: The aim was to examine how the radiographer's adherence to hand hygiene practices can be improved. Method: An integrative literature review where scientific articles were searched in the PubMed and CINAHL databases. 15 articles have been quality reviewed, categorized, analyzed and finally the result has been compiled and a synthesis written. Result: Different types of interventions, such as education, information, automated observation systems and multimodal interventions, can be helpful in improving compliance with hand hygiene routines. Conclusion: Practical and theoretical education, dedicated management and a responsible climate combined with good access to hand hygiene products and reminders to perform hand hygiene are important parts of the work to improve compliance with hand hygiene routines.

Tese(doutorado) - Universidade Federal do Rio Grande, Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, 2011.
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A presente pesquisa teve por objetivos: compreender, quanto à fundamentação teóricofilosófica e organizativa, como os Documentos do MS tratam a pesquisa em saúde no Brasil; delinear, a partir da fundamentação teórico-filosófica e organizativa, presente no conjunto de documentos oficiais do MS que trata da pesquisa para a saúde no Brasil, uma Rede Ecossistêmica de Pesquisa em Enfermagem/Saúde nos HUs Federais, para auxiliar na consolidação do SUS. Traçou-se a seguinte TESE: É possível delinear, a partir da fundamentação teórico-filosófica e organizativa, presente no conjunto de documentos oficiais do MS que trata da pesquisa para a saúde no Brasil, uma Rede Ecossistêmica de Pesquisa em Enfermagem/Saúde nos HUs Federais, para auxiliar na consolidação do SUS. Para sustentar a referida tese, procurou-se, no referencial contextual e teórico, os temas: Sistema Único de Saúde – SUS; Hospitais Universitários Federais na perspectiva ecossistêmica; Pensamento Sistêmico, numa Abordagem Ecossistêmica; Interfaces da Pesquisa Ecossistêmica nos HUs Federais e a Pesquisa Ecossistêmica em rede na enfermagem/saúde. Ele mostrou-se coerente, consistente e ancorador em relação à análise e à interpretação dos dados e permitiu aprofundar o conhecimento sobre a temática. O caminho metodológico caracterizou-se como exploratório, descritivo, com abordagem qualitativa. Para capturar os dados, utilizou-se um instrumento de pesquisa documental, estruturado em três pilares básicos, que contemplaram os aspectos capazes de abranger o escopo da proposta. Contemplando objetivo, questão de pesquisa e tese foram desenvolvidos, com base nos dados capturados, três artigos: SUS e a Pesquisa Ecossistêmica em Enfermagem/Saúde: estratégia de inovação na produção de ciência, tecnologia e assistência em saúde; Rede Ecossistêmica de Pesquisa em Enfermagem/Saúde nos HUs Federais e Rede Ecossistêmica de Pesquisa em Enfermagem/Saúde nos Hospitais Universitários Federais: uma possibilidade para a Pesquisa em Enfermagem/Saúde. Os resultados do primeiro artigo mostraram que, ao promover a Pesquisa Ecossistêmica em Enfermagem/Saúde nos HUs Federais, existem possibilidades de produzir inovação no pensar e fazer e, assim, alcançar resultados mais positivos na assistência, induzindo à sustentabilidade ao Sistema. O segundo enfatiza que as ações de pensar e fazer, balizadas pelo princípio sistêmico integrador, expresso em rede, podem aumentar as interfaces entre pesquisadores de diversas áreas investigativas e suas concepções metodológicas e, assim, alavancar ciência e tecnologia e capacitação científica ao trabalhador de enfermagem/saúde e inserir ganho na prestação da assistência/saúde. O terceiro demonstra que, por meio de um modelo mental ancorado em referencial ecossistêmico, é possível delinear uma Rede Ecossistêmica de Pesquisa em Enfermagem/Saúde em HUs Federais. Considera-se que o SUS necessita ser constantemente repensado, a fim de buscar e obter soluções pertinentes; precisa inovar, evoluir, especialmente na pesquisa, e promover qualidade no ensino, na assistência à saúde e no ambiente, até mesmo, para a sua própria manutenção como sistema de saúde.
The objective of this research was to outline an Ecosystemic Net of Research in Nursing/Health in Federal University Hospitals in order to help consolidate the Integrated Healthcare System, based on the theoretical-philosophical and organizational basis which is found in official documents issued by the Ministry of Health about research in health in Brazil. The following THESIS was analyzed: In order to help the consolidation of the Integrated Healthcare System, it is possible to outline an Ecosystemic Net of Research in Nursing/Health in Federal University Hospitals, based on the theoretical-philosophical and organizational basis which is found in official documents issued by the Ministry of Health about research in health in Brazil. In order to support this thesis, the theoretical section of this study involved these themes: the Integrated Healthcare System, Ecosystemic Research in the Integrated Healthcare System and Federal University Hospitals from the perspective of Ecosystemic Research. It was coherent, consistent and primordial regarding the analysis and the interpretation of data and enabled to deepen knowledge of the theme. The methodology was characterized as exploratory and descriptive in a qualitative approach. In order to collect data, a specially designed documentary research tool was used; its structure has three basic pillars which comprised the fundamental aspects and some secondary ones that were able to embrace the whole scope of the proposal. Regarding the objective, the question and the thesis, three papers, based on the data collected in the official documents issued by the Ministry of Health, were written: “The Integrated Healthcare System and Ecosystemic Research in Nursing/Health: an innovation strategy in the production of science, technology and healthcare”; “An Ecosystemic Net of Research in Nursing/Health in Federal University Hospitals”; and “ An Ecosystemic Net of Research in Nursing/Health in Federal University Hospitals: a possibility of research in Nursing/Health”. The results of the first paper showed that, when Ecosystemic Research in Nursing/Health is promoted in Federal University Hospitals, it is possible to bring innovation to thoughts and actions which aim at getting more positive results in healthcare and to make the Integrated Healthcare System more sustainable. The second paper highlights that actions and thoughts that are mediated by an integrative systemic principle, expressed in a net, may strengthen the interfaces among researchers from different areas and their methodological conceptions. Consequently, science and technology will be enhanced, workers in Nursing/health will get more scientific knowledge and healthcare will be considerably enriched. The third one shows that, based on a mental model attached to ecosystemic references, an Ecosystemic Net of Research in Nursing/Health may be outlined in Federal University Hospitals. The Integrated Healthcare System needs to be constantly reviewed so that it may look for and find adequate solutions, innovate, evolve - mainly in research - and improve the quality of teaching, of healthcare and of the environment in order to be maintained as an integrated healthcare system.
La presente investigación tuvo los seguientes objetivos: comprehender, cuanto la fundamentación teórica-filosófica y organizativa, como los documentos del MS tratan la investigación en salud en Brasil; delinear, partiendo de la fundamentación teórico-filosóficas y organizativa, presente en el conjunto de documentos oficiales del MS que trata de la investigación para la salud en Brasil, una Red Ecosistémica de Investigación en Enfermería/Salud en los HUs federales para la consolidación del SUS. Fue elaborada la siguiente TESIS: Es posible delinear, partiendo de la fundamentación teórico-filosófica y organizativa, presente en el actual conjunto de los documentos oficiales del MS que proviene de la Investigación de la Salud en el Brasil, una Red Ecosistémica de Investigación de Enfermería / Salud en los HUs Federal, para ayudar a la consolidación del SUS. Para sostener la referida tesis, fue buscado en el referencial contextual y teórico, los temas: Sistema Unificado de Salud – SUS; Hospitales Universitarios Federales en el enfoque ecosistémico; Pensamiento sistémico, un enfoque ecosistémico; Interfaces de Investigación de Ecosistémica en los HUs Federales y la Investigación Ecosistémica en red en la enfermería/salud. Él resultó ser coherente, consistente y anclado en relación al análisis y la interpretación de datos y permitió profundizar conocimientos sobre el tema. El enfoque metodológico es caracterizado como exploratorio, descriptivo, con enfoque cualitativo. Para capturar los datos, se utilizó la herramienta de investigación documental, estructurado en tres pilares básicos, que contemplan aspectos capaces de cubrir el alcance de la propuesta. Contemplando objetivo, la cuestión de investigación y tesis han desarrollado, sobre la base de los datos capturados, tres artículos: SUS y la Investigación Ecosistémica en Enfermería/Salud: Estrategia la innovación en la producción de ciencia, tecnología y cuidados de salud; Red Ecosistémica de Investigación en Enfermería /Salud en los Hospitales Federales y Red Ecosistémica de Investigación en Enfermería/Salud en los Hospitales Universitarios Federales: una oportunidad para la Investigación Enfermería/Salud. Los resultados del primer artículo mostraron que, mediante la promoción de la investigación ecosistémica de Enfermería / Salud en los HUs Federales, existe la posibilidad para producir la innovación en el pensamiento y la acción y así lograr resultados más positivos en la asistencia, induciendo la sostenibilidad del Sistema. El segundo enfatiza las acciones de pensar y hacer, impulsado por el principio sistémico integrador, expresado en red, pueden aumentar las interfaces entre los investigadores de diferentes áreas de investigación y sus puntos de vista metodológico y por lo tanto, dar importancia a la ciencia, la tecnología y la formación científica del trabajador de la Enfermería/Salud y inserir puntos positivos a la prestación de atención/salud. El tercero muestra que a través de un modelo mental anclado en un referencial ecosistémico, es posible delinear una Red Ecosistémica de Investigación en Enfermería/Salud en HUs Federales. Se considera que el SUS tiene que ser constantemente repensado a fin de solicitar y obtener las soluciones adecuadas; para innovar, desarrollar, especialmente en la investigación y promover la calidad en la enseñanza, en la asistencia a la salud y el ambiente, incluso para su propio mantenimiento como sistema de salud.

Advances in medical technology have altered the need for certain types of surgery to be performed in traditional inpatient hospital settings. Less invasive surgical procedures allow a growing number of medical treatments to take place on an outpatient basis. Hospitals face growing competition from ambulatory surgery centers (ASCs). The competitive threats posed by ASCs are important, given that inpatient surgery has been the cornerstone of hospital services for over a century. Additional research is needed to understand how surgical volume shifts between and within acute care general hospitals (ACGHs) and ASCs. This study investigates how medical technology within the hospital industry is changing medical services delivery. The main purposes of this study are to (1) test Clayton M. Christensen’s theory of disruptive innovation in health care, and (2) examine the effects of disruptive innovation on appendectomy, cholecystectomy, and bariatric surgery (ACBS) utilization. Disruptive innovation theory contends that advanced technology combined with innovative business models—located outside of traditional product markets or delivery systems—will produce simplified, quality products and services at lower costs with broader accessibility. Consequently, new markets will emerge, and conventional industry leaders will experience a loss of market share to “non-traditional” new entrants into the marketplace. The underlying assumption of this work is that ASCs (innovative business models) have adopted laparoscopy (innovative technology) and their unification has initiated disruptive innovation within the hospital industry. The disruptive effects have spawned shifts in surgical volumes from open to laparoscopic procedures, from inpatient to ambulatory settings, and from hospitals to ASCs. The research hypothesizes that: (1) there will be larger increases in the percentage of laparoscopic ACBS performed than open ACBS procedures; (2) ambulatory ACBS will experience larger percent increases than inpatient ACBS procedures; and (3) ASCs will experience larger percent increases than ACGHs. The study tracks the utilization of open, laparoscopic, inpatient and ambulatory ACBS. The research questions that guide the inquiry are: 1. How has ACBS utilization changed over this time? 2. Do ACGHs and ASCs differ in the utilization of ACBS? 3. How do states differ in the utilization of ACBS? 4. Do study findings support disruptive innovation theory in the hospital industry? The quantitative study employs a panel design using hospital discharge data from 2004 and 2009. The unit of analysis is the facility. The sampling frame is comprised of ACGHs and ASCs in Florida and Wisconsin. The study employs exploratory and confirmatory data analysis. This work finds that disruptive innovation theory is an effective model for assessing the hospital industry. The model provides a useful framework for analyzing the interplay between ACGHs and ASCs. While study findings did not support the stated hypotheses, the impact of government interventions into the competitive marketplace supports the claims of disruptive innovation theory. Regulations that intervened in the hospital industry facilitated interactions between ASCs and ACGHs, reducing the number of ASCs performing ACBS and altering the trajectory of ACBS volume by shifting surgeries from ASCs to ACGHs.

Yes
Underpinned by a contemporary view of automotive systems as cyber-physical systems, characterised by progressively open architectures increasingly defined by their interaction with the users and the smart environment, this paper provides a critical and up-to-date review of automotive Integrated Vehicle Health Management (IVHM) systems. The paper discusses the challenges with prognostics and intelligent health management of automotive systems, and proposes a high-level framework, referred to as the Automotive Healthcare Analytic Factory, to systematically collect and process heterogeneous data from across the product lifecycle, towards actionable insight for personalised healthcare of systems.
Jaguar Land Rover funded research “Intelligent Personalised Powertrain Healthcare” 2016-2019

碩士
輔仁大學
資訊管理學系
97
As the population structure gradually reaches to aging society as well as the economical structure, lifestyle, and the levels of medical technology are developing with the aging population structure, longevity making the incidence of chronic diseases increased. One of these issues of chronic diseases can’t be ignored in an aging society. Two critical problems are derived from chronic diseases, one of problems for patients who have heavy pressures on physiology and psychology because of suffering from chronic diseases. Another problem is the long-term care becoming a heavy burden to patients and their families. The medical services are not enough at-home or outdoor activities. In view of this, we hope to develop a healthcare system to help caregivers to provide the care to the cared people who are in the community and outdoors by taking the advantage of the healthcare system integrates wireless communication technology, wireless sensor technology, and radio frequency identification technology. It combines with a series of vital sign sensors, RFID tag, and various handheld devices. these technologies are used to constantly monitor, in the meanwhile to transport patients’ vital sign such as blood sugar, blood pressure, and body temperature to the healthcare management system of the healthcare institution so that the cared people can obtain the most real-time and proper care from caregivers. We use fuzzy expert system to analyze data collected and orientate the location of care-receivers through GPS positioning in emergency time. This study hopes to help doctors to quickly obtain the status of all care-receivers.

Indiana University-Purdue University Indianapolis (IUPUI)
Health Information Technology (HIT) has become an integral component of healthcare today. The HITECH Act (2009) and Meaningful Use objectives stand to bring wide-sweeping adoption and implementations of HIT in small, medium and large sized healthcare organizations across the country. Though recent literature has provided evidence for the benefits of HIT in the profession, there have also been a growing number of reports exploring the adverse effects of HIT. There has not, however, yet been a systematic account of the adverse effects of HIT in the healthcare system. The current push for HIT coupled with a lack of critical appraisal of the potential risks of implementation and deployment within the medical literature has led to a general unquestioning and unregulated acceptance of the implementation of technology in medicine and healthcare as a positive addition with little or no risk. While the benefits of HIT are clear, a review of the existing studies in the literature would provide a holistic vision of the adverse effects of HIT as well as the types and impact within the nation’s health care system to inform future HIT development and implementation. The development of a general understanding of these adverse effects can serve as a review and summary for the use of informatics professionals and clinicians implementing HIT as well as providing future direction for the industry in HIT implementations. Additionally, this study has value for moving forward in informatics to develop frameworks for implementation and guidelines and standards for development and regulation of HIT at a federal level. This study involves the use of an integrative literature review to identify and classify the adverse effects of HIT as reported in the literature. The purpose of this study is to perform an integrative review of the literature to 1) identify and classify the adverse effects of HIT; 2) determine the impact and prevalence of these effects; 3) identify the recommended actions and best practices to address the negative effects of HIT. This study analyzed 18 articles for HIT-induced error and adverse consequences. In the process, 228 errors and/or adverse consequences were identified, classified and represented in an operational taxonomic schema. The taxonomic representation consisted of 8 master categories and 30 subcategories. Additionally, the prevalence and impact of these errors were evaluated as well as recommendations and best practices in future systems design. This study builds on previous work in the medical literature pertaining to HIT-induced errors and adverse consequences and offers a unique perspective in analyzing existing studies in the literature using the integrative review model of research. It is the first work in combining studies across healthcare technologies and analyzing the adverse consequences across 18 studies to form a cohesive classification of these events in healthcare technology.

eHealth and mobile apps is a growing market in today millennium technologies. Despite the increase number of mobile apps related to health and wellbeing including weight loss and obesity, there are many aspects influencing its effectiveness that remain unclear. The aim of this dissertation is to understand how Portuguese population will respond to eHealth technology development for information exchange and weight management within healthcare systems. It looked closely to the advantages and understanding the power of eHealth in exchange information between Healthcare providers and patients. This dissertation met the research aim through detailed study of relevant literature, to state the problematic questions that were tested using qualitative and quantitative analysis. Rq1: Will empowering patients with higher access to information exchange reduce healthcare costs? Focusing on medication management? Rq2: Will patients adhere and engage positively to healthcare information within an integrated healthcare services? Rq3: Will a development strategy towards overweight management using mobile apps reduce worldwide healthcare costs? It concluded that there is an increase of eHealth usage by younger generations and that there are predominant effects on using internet for information exchange and to engage patients to increase knowledge on our healthcare services. It also scoped through effects of eHealth apps towards obesity prevention. Further research is needed to develop a meta-analysis between costeffectiveness of developing eHealth apps for the national healthcare system in order to increase patient adherence for information exchange, control medication management and reduce obesity or overweight populations.

碩士
中原大學
醫學工程研究所
96
The concept of Tele-medicine has emerged since (for example late 1950) and it has been evolving into a real-world application nowadays. Nevertheless, Tele-medicine is still facing a number of challenges on multiple fronts. In major society, patient-doctor direct consultation is still considered as the best health treatment method. Tele-medicine development is also hindered by a lack of regulation standards in medical area. Communication technology, as backbone for Tele-medicine was not as sophisticated as recent time. Those three factors are perceived to constraint the development and implementation of Tele-medicine system. Tele-consultation system, as one of the supporting elements of Tele-medicine has been designed and implemented to demonstrate the basic, general purpose Tele-medicine system. There are two functions integrated in the system. The first function is remote real-time ECG monitor. The second function is the bi-directional audio and video transmission. The implementation of the framework is based on the Microsoft DirectShow environment. The MIT ECG database is utilized to simulate ECG signal on the patient-side. The system can transfer the bi-directional video through Ethernet 10/100 Mbps network with 320 x 240 pixel resolution without particular coding algorithm. The frame rate can be up to 25 fps. The audio is transmitted using 44.1 kHz sample rate with 16 bit resolution per sample. The remote side can monitor the ECG signal at 360 Hz rate and 11 bit resolution synchronously. The system can provide the basic form of the bi-directional video transmission and general remote bio-signal monitor as foundation for Tele-healthcare and Tele-consultation applications.

碩士
南台科技大學
資訊工程系
95
Cardiovascular diseases are major causes of death recently according to the ten causes of death, which was analyzed statistically by Department of Health. And arterial illnesses are the most major causes. Nevertheless, health monitor services of home- and community-care are developed in many countries when the ageing society is coming. The clinician can get the information of patients through Internet, regular monitor the physiological parameters and provide remote health care. Pulse Wave Velocity (PWV) was used as a parameter for evaluating arteriosclerosis condition recently. The goal of the study is to design a cardiovascular evaluation system, which is based on the algorithmic techniques. The multi-function measurement can be selected to calculate PWV from the signals includes electrocardiogram, heart sounds, photoplethysmography and pressure waveforms. The several analyses of PWV can be getting immediately after the record signals are uploaded to the server. The clinician can also monitor the conditions of the patients by monitoring both of the waveforms and the parameters. The evaluation of the clinician can transmit to the server through Internet, and then the patient gets the evaluation and suggestions of health condition at home. Consequently, the evaluations of PWV and the monitor of clinician can used to assess the disorder condition of cardiovascular system and establish remote home care.

碩士
國立陽明大學
醫務管理研究所
91
The heath care industry in Taiwan has been blooming since the implementation of National Health Insurance (NHI) System on 1995. To keep pace with the rapidly changed claim system for reimbursement of NIH, Most of the hospitals in Taiwan have already set up the Healthcare Information systems. To increase the effectiveness and efficiency of the hospital management, and to integrate all the information, to set up a HIS (Healthcare Information System) in Hospital is essential. The maturity of information technology helps upgrade the HIS. How to invest effectively on HIS and integrate all the information systems in the health care delivery system, and to support the CEO to do better decision making, is an important issue. Therefore, in face of the highly changeable environment, how to take the advantages of information technology, is this case study aimed for. The build-up for all the regional Veterans Hospitals in Taiwan has went into the second stages of the whole island-wide Veterans Hospitals Healthcare Information Network. This case study also tries to build a set-up model for the 12 Regional Veterans Hospitals by VAC in Taiwan. The model of Shared Health Information System mentioned in this study shows that through integrated development and mass purchasing, the hospitals will reduce the implementation cost, standardize the health information system, unify the operation and take the advantages of shared Information.

碩士
臺北醫學大學
醫學資訊研究所
93
Since 1996, government had practiced ’Integrated Health Care Delivery System Project (IDS Project)’ in aboriginal area in order to obtain enough medical care service for residents of aboriginal area. This project solved the problem of inadequate resources, but it made new problems that repeated investment of medical resources due to lack of information integration between the responsible hospitals and public clinics of aboriginal area. Therefore, building a system to integrate the medical information will help using resources effectively. In this study, we have built a web-based system to integrate health records of residents in aboriginal area. The prototype has been established in A-Li-Shan area. To evaluate this system we constructed the questionnaire based on Information System Success Model (ISSM). The result showed that users satisfied this system and this system indeed is useful for sharing medical information. This work will provide reference for the other aboriginal area in Taiwan.

BARNA, Alexander: Trauma readiness of emergency medical services in the Czech Republic and Slovak Republic [Diploma thesis]. University of South Bohemia in České Budějovice, Faculty of Health and Social Sciences. Lecturer: Mgr. Zuzana Freitinger-Skalická, Ph.D. The main topic of this work was the introduction of the issue of trauma readiness of the emergency medical service in the Czech Republic and the Slovak Republic, the issue of emergency events with mass casualty incidents and the mapping of the knowledge and orientation of paramedical personnel in the emergency medical services. The diploma thesis is divided into two major parts - theory and research. The theoretical part introduces legislative norms, regulations and expert recommended procedures, based on which providers of emergency health services ensure their activity and crisis readiness, especially through crisis readiness workplaces. The chosen issue in the research part was the knowledge of the members of the emergency medical services groups solved by the quantitative method - a survey carried out by means of an anonymous non-standardized questionnaire, was prepared individually for the Czech Republic and for the Slovak Republic. From the results of the questionnaire survey it can be deduced that the knowledge of the members of the emergency medical service groups is sufficient, but there is still a need to incorporate the expertise and knowledge of the trauma readiness issues. Above all, finding deficiencies in knowledge, which are used to carry out rescue and liquidation work in dealing with emergency events, is particularly problematic.