Outsourcing involves contracting out a function, or functions, performed by an organization to another organization available in the market. It involves transferring the services, performed by internal staff, as well as the staff themselves, to an external service provider under a contractual agreement. Today in healthcare, many organizations are exploring outsourcing as a way to address demands for health information technology (HIT). This thesis researches the success of outsourcing in the health informatics industry in Canada. The study is designed to help understand whether outsourcing HIT functions, such as development, implementation, operations, and maintenance, can prove successful and result in benefits for an organization. The study finds that outsourcing all four functions of HIT development, implementation, operations, and maintenance occurs in Canada; however, the research from the semi-structured interviews finds that operations and maintenance may be more commonly outsourced in Canada, over development and implementation functions. Despite this, the research from the semi-structured interviews finds that outsourcing development and implementation may actually offer more benefits and fewer challenges than outsourcing operations and maintenance. The research also finds that there can be many benefits of outsourcing for organizations, such as gaining access to expertise and improving service levels, as well as many weaknesses of outsourcing, such as losing internal knowledge and having to manage the change required from outsourcing. The findings from this thesis were used to develop a conceptual model that can be used when an organization is looking at outsourcing. The model considers the inputs and the outputs to outsourcing as an organizational strategy, including the factors that influence an organization’s decision to outsource, the risk and challenges associated with outsourcing, and the expected outcomes and benefits that can result from outsourcing. The study proposes that there are many things that need to be considered when outsourcing to ensure it is successful. / Graduate / 0769 / smalovec@gmail.com

Background: To be able to live independently, older persons can use technology-based health communication (HC) for support, guidance, and contact with health care professionals within their home environment. Informal caregivers who assist in different situations can also find support in their caring role using technology. The study of mobile technologies is an important research area in gerontechnology. Nevertheless, there is a gap of research in technology-based HC utilized by older persons, including preferences related to cognitive impairment (CI) in a home environment. Aim: The overall aim of the thesis was to define the concept and describe experiences of HC within the home environment from a gerontechnological perspective. The aim of Study I was to identify and construct the meaning of HC from the perspective of older persons in need of care in the home environment and their informal caregivers. The aim of Study II was to describe how older persons with CI experienced technology-based HC through the use of a mobile application in order to facilitate a sense of coherence. Method: This thesis has a naturalistic approach. In Study I, the evolutionary model of concept analysis was used, based on a systematic literature review including 29 studies. In Study II, semi-structured interviews were conducted with 16 older persons with CI. The transcripts were analyzed with a deductive thematic analysis. Findings: The defining attributes of the concept HC identified in Study I were: Resources of the recipient, Influence on decisions, and Advantages of tailored information. These attributes led to the following descriptive definition of HC: Tailored information, based on needs and resources of the recipient influence care decisions. The findings of Study II resulted in an overall theme: A technology that supports but creates challenges. Further, the analysis yielded the following three themes, with associated subthemes: Making sense of mobile technologies, Mastering mobile technologies, and Added value to use mobile technologies. Conclusion: Technology-based HC utilized by older persons and their informal caregivers within the home environment emphasizes suiting needs, capacity and preferences to be considered useful. Influences of the context, the home environment also needs to be taken into account when developing technology-based HC and mobile technologies for this purpose.

BackgroundApplied health technology is a research field that ties together several disciplines to improve and preserve the health and quality of life of individuals and society. Helping especially elderly to meet the above goals is an important and necessary task and assistive technology and collection of health data are part of this work. AimsPaper I aims to investigate whether the use of a powered toothbrush could maintain oral health in a group of individuals with MCI and if changes in oral health affect various aspects of quality of life. Paper II and III aims to examine the capacity of a powered toothbrush as a carrier and mediator of health-related data. MethodsFor papers I and II, the participants were recruited from the Swedish site of the multicenter project Support Monitoring And Reminder Technology for Mild Dementia and for paper III from the Department of Health at Blekinge Institute of Technology. In all three papers, a powered toothbrush has been used as a tool, sensor carrier and transmitter of data. For Quality-of-life assessment two instruments are used, The QoL-AD and OHIP 14. ResultsBy introducing an intelligent powered toothbrush in the group of older individuals with mild cognitive impairment we have showed that they, regardless of cognitive level,improved their scores for plaque index, bleeding index and deepened periodontal pockets ≥ 4mm, over 12 months. The quality-of-life instrument related to oral health improved in parallel with the improvement in oral health. Furthermore, it is possible to use the intelligent powered toothbrush both as a carrier for healt related sensors and to transfer user data via Bluetooth technology to a single-core processor that stores or forwards the data via Wifi to an external computer for processing, analysis and storage. A fesibility study regarding temperature sensor for measuring body temperature during toothbrushing have been evaluated and found to be comparable to traditional oral temperature measurement.   ConclusionsAn intelligent powered toothbrush is a well-functioning tool for maintaining oral health in older people with mild cognitive impairment as well as for collecting and transferring brush and health data to external units for storage and analysis.

Mortality rates in the United States are higher for men than they are for women as a result of chronic diseases such as heart disease, cancer, and diabetes. Despite these disproportionate rates, few health interventions are targeted to men, and limited knowledge exists regarding the specific components needed to design technology health tools to appeal to men. The purpose of this quantitative study was to examine the relationship between the use of technology health tools and the role of self-efficacy in men and the influence on participation in healthy lifestyle behaviors. A quasi-experimental design was used to analyze data collected from the Health Information National Trends Survey (N = 990). A group of men (n = 323) who used technology health tools were compared to a control group of men (n = 667) who did not use technology health tools. Results from the regression analysis indicated that the use of technology health tools for self-management of health behavior had a significant effect on participation in healthy lifestyle behavior (p = .026). Self-efficacy was also found to mediate the relationship between technology health tools and participation in healthy lifestyle behavior (p = .018). This study supports the United States federal government's Healthy People 2020 objective to increase the proportion of people who use Internet health management tools. The implications for positive social change include knowledge for developing targeted technology health interventions to increase the participation of men in healthy lifestyle behavior, reduce the number of men with chronic diseases, improve chronic disease management, and reduce healthcare costs in the United States.

Health portals are dedicated web pages for medical practices to provide patients access to their electronic health records. The problem identified in this quality improvement project was that the health portal in the urgent care setting had not been available to staff nor patients. To provide leadership with information related to opening the portal, the first purpose of the project was to assess staff and patients' perceived use, ease of use, attitude toward using, and intention to use the portal. The second purpose was to evaluate the portal education materials for the top 5 urgent care diagnoses: diabetes, hypertension, asthma, otitis media, and bronchitis for understandability and actionability using the Patient Education Material Assessment Tool, Simple Measures of Goobledygook, and the Up to Date application. The first purpose was framed within the technology acceptance model which used a 26-item Likert scale ranging from -3 (total disagreement) to +3 (total agreement). The staff (n = 8) and patients (n = 75) perceived the portal as useful (62%; 60%), easy to use (72%; 70%), expressed a positive attitude toward using (71%; 73%), and would use the technology (54%; 70%). All materials were deemed understandable (74%-95%) with 70% being the acceptable percentage. Diabetes, otitis media, and bronchitis were deemed actionable (71-100%), but hypertension (57%) and asthma (40%) had lower actionability percentages. Hypertension, asthma, and otitis media had appropriate reading levels (6-8th grade). However, diabetes (10th grade) and bronchitis (12th grade) were higher with the target being less than 8th grade level. All handouts were found to be evidence-based. Recommendations were to revise the diabetes and bronchitis educational handouts to improve readability. Social change can be promoted by this project by facilitating positive patient outcomes at urgent care clinics.

Access to assistive technologies (AT) is necessary to achieving all 17 sustainable development goals. Yet for most people who need AT in Southern Africa, AT is unaffordable, unavailable, and often inappropriate. My PhD research was guided by the core question: What works to increase access to assistive technology in Southern Africa? Organized into three sub-studies, my research aimed to identify and describe the facilitators and barriers to access AT and develop a theoretical model to inform strategies to increase AT access in Southern Africa. The first two sub-studies listed below were previously published and the full manuscripts are included as separate chapters within the thesis. The three sub-studies included: • Sub-study 1: A scoping review that characterized existing evidence on AT from resource limited environments. Evidence identified was limited in quantity and quality, and primarily focused on mobility and vision types of AT. • Sub-study 2: A secondary analysis (i.e., bivariate regressions) of national survey data from Botswana and Swaziland served to examine factors associated with higher levels of AT access. The type of disability (i.e., mobility vs. non-mobility) was found to be the most important factor in determining AT access in both countries. • Sub-study 3: A regional qualitative sub-study was conducted to increase the understanding of how a multitude of interrelated factors operate to increase the supply of and access to AT. An adapted health systems framework was applied to analyse multiple data sources including stakeholder interviews, documentation review and observations. The thesis is organized into seven chapters. In Chapter 1, I provide background information and conceptual framing of the research topic, assistive technology access within Southern Africa. The research questions and overview of the three sub-studies are included in this introductory chapter. Chapter 2 covers the research methods of all three sub-studies. For the first two sub-studies, a brief overview of data collection and analysis methods are included that reference the more detailed methods presented within each published manuscript. The first two sub-studies are presented as Chapter 3 (scoping review) and Chapter 4 (secondary analysis) within the thesis. The third sub-study (qualitative) provided the most comprehensive data of the three sub-studies and comprises findings presented in Chapter 5 and Chapter 6. In the final chapter, Chapter 7, I synthesize findings from all three sub-studies to identify prominent patterns and present models that aim to explain constraints within the AT sector. The synthesis of evidence showed that AT in Southern Africa does not operate as a sector but as a constellation of uncoordinated parts. The low prioritization of AT and high level of fragmentation within the system emerged as pervasive patterns. The combination of these two patterns result in a wasteful sector. This means that the limited resources invested in funding products and services, and in strengthening the national AT procurement and provision system are not used effectively to increase the supply of and access to appropriate AT. In my further interpretation of data to respond to the core research question: What works to increase access to assistive technology in Southern Africa? I then identify strategic levers to increase AT access. Strategic levers aim to increase resources invested in the AT sector while reducing system-wide inefficiencies. Finally, study limitations and conclusions are presented at the end of this final chapter.

High quality T-cell immunogenicity can be an elusive type of immunity to generate and one that is often sought after by virologists, immunologists and cancer researchers alike. When T-cell immunity is generated using current methodologies the quality and magnitude of the immunological response achieved is often weak and unable to create protective immunity. Among current methods, DNA vaccines, generate highly specific T-cell immunity towards targeted antigens, and do not suffer from issues like misdirected vector targeted immunity, like viral based vectors. DNA vaccines, however, face a variety of their own weaknesses. These include, inefficient delivery, high biological loss inside the body, and the inability to counteract or avoid immediate innate cellular defence mechanisms, which limit their ability to persist inside a host cell. For these reasons, DNA vaccines are usually combined with more conventional viral vaccines in what is known as a DNA prime and viral boost regiment strategy. Combining them works well and results in improved immunity towards targeted antigens that is superior to what is obtained when either DNA or recombinant vaccines are used alone. To address many of the core issues faced by DNA vaccines, I report here on the design, development and characterization of a self-replication DNA gene expression technology. This novel DNA expression system employs a form of DNA replication (known as rolling circle replication) to generate a self-replicating DNA amplicon that can amplify its own copy number and the relative localised levels of antigen expression inside transfected mammalian cells in tissue culture and within Balb/cJ mice. These capabilities help effectively mitigate many of the core issues faced by DNA vaccines. The technology developed was shown to significantly increase gene expression for eGFP and Luciferase reporter genes, with an overall average increase in expression of approximately two-fold by 48 h post transfection in HeLa S3 cells. More specifically, an increase of at least two-fold in the absolute maximum level of the gene of interest per cell was also observed. Such localised doubling in antigen expression, at the cellular level, is believed to enhance innate immune activation and improve the overall immune response. Experimental results indicated that gene expression levels by this technology is non static in nature and appears to increase in magnitude within affected cells over time as was hypothesised. This provided strong evidence that the replication technology appears to be functioning as was expected and was able to demonstrate the ability to elevate antigen expression over time, potentially starting from extremely low and otherwise ineffective starting concentrations. This ability has potential to effectively mitigate many of the issues associated DNA vaccines such as low and ineffective delivery. This capability was observed in tissue culture as a steady increase in reporter gene expression levels across the entire range of DNA transfection levels. Furthermore, the increases in gene expression were observed to continue to amplify over time, eliminating the presence of weakly fluorescing cells in tissue culture. By 11 days post transfection, every observable cell transfected with the replication expression system, was observed to have extremely high levels of fluorescence. With recorded fluorescence levels being as bright or brighter than the highest levels obtained under normal transfections with no replicative plasmids (~48-72 h). Unique cellular responses to the presence of the replicating gene expression technology were also observed. These included an apparent slowdown in cellular metabolic activity and growth among cells transfected with replicating vectors. This was observed as a decrease in cellular division and total cell number by ~50%, by 48 h post transfection. This was accompanied by significant increases in cell size, internal cellular granularity, and gene-of-interest expression per cell. These changes were observed among all cells regardless of their relative DNA transfection level. This was demonstrated by assessment of the change in the range, mean, median, skewness and standard deviation of the cellular distribution curves for eGFP expression, cell size and internal cellular granularity. These observations provided further evidence of the dynamically changing and active nature of this technology. This also provided evidence that the replicating gene expression technology has a definitively different kind of cellular impact and effect on transfected cells compared to non-replicating DNA expression systems. Pilot studies to test the technology in Balb/cJ mice indicated, the technology appears to be functional within this animal model and was able to increase gene of interest (eGFP) expression levels compared to an equivalent non-replicating DNA expression vector control. Furthermore, these animal experiments also demonstrated significant increases in the maximum possible level of expression achieved within localised ‘hot spots' of muscle fibre bundles. This effect appeared to increase following transient addition of additional replication associated protein (Rep), giving further evidence this technology appears to be functional within the Balb/cJ animal model. Suggesting that the rate at which the replication amplification process occurs, may also be manipulated by adjusting Rep concentration. Finally, an antiviral response gene array was run to look for evidence that the replicating gene expression technology could increases antiviral response gene activation, to possibly improve T-cell activation and immunity. The array provided evidence improved antiviral response gene activation was occurring however the data was inconclusive in nature and further investigation is needed to verify these preliminary findings. The array also showed significant evidence of Rep induced Caspase 10 (CASP10), gene suppression. This suggests that Rep may play a role in the survival and virulence ofBFDV by acting as a suppressor of cellular apoptosis in a concentration-dependant manner and is worth investigating further.

Following the successful introduction of antiretroviral therapy (ART) in resource-limited settings, we have observed an unprecedented explosion in the expansion of ART programs throughout sub-Saharan Africa, resulting in a 13-fold increase in coverage since 2004. In spite of these achievements, uptake of ART remains low. The gap in treatment coverage is approximately 50% of those who need ART in South Africa, while the country boasts the largest ART program worldwide. Rural areas are particularly prone to lower ART coverage rates, largely a result of existing health care inequities. The ART coverage gap will widen given the recent introduction of new treatment guidelines, which allows for ART commencement at CD4 350 cells/mm3. Furthermore, approximately one-third of ART patients are lost to follow up after two years of treatment initiation in sub-Saharan Africa. This study explores factors associated with ART access and utilisation in a rural area, in order to reduce the gap in knowledge on patient and health system factors. Unaddressed, these factors may continue to hinder adoption of rigorous interventions to improve ART uptake and retention. This research employs the A-Framework to conceptualize access to health care, where dimensions of access include availability (physical access), affordability (financial access), and acceptability (cultural access). A data triangulation approach was adopted as very little was known on the utilization patterns of health care by HIV/AIDS patients. Quantitative research (2008-2010) employed a four-site rural-urban comparative analysis of 1266 participants, and was part of a 5-year project Researching Equity and Access to Health care (REACH).This was complemented by a more in-depth qualitative assessment (2006-2007) that followed the treatment experience of 32 patients before and after ART initiation in the rural Bushbuckridge site. We found plural utilisation of health care to be a cross-cutting theme throughout this thesis. While the movement of patients between providers at various levels within the traditional and formal health sector may be a sign of agency, it may also result in excessive health costs that threaten the livelihoods of individuals and their households. We discuss a number of strategies to improve ART initiation and adherence including the need to incorporate metrics for pluralism into routine assessments; the importance of decentralized, humane and high quality care and support services; support for efforts to enhance patient self-efficacy through education, awareness and social support interventions; the incorporation and regulation of traditional healers into the formal system; risk protection mechanisms that reduce financial barriers and consequences of HIV care including grants, subsidies and National Health Insurance, and support for wider efforts to reduce urban-rural inequalities.

The basic aim for any software development organization is to maximize value creation for any given investment. To amplify and speed up value creation efforts, Agile Software Development has gained much popularity during the last decade as a response to a volatile and disruptive market. In an Agile environment, the team focuses on lightweight working practices, constant deliveries and customer collaboration rather than heavy documentation and inflexible processes. However, the Agile way of working has complicated how an organization can control and evaluate the process; allowing organizations to believe that all Agile processes is the ideal process. This master thesis was conducted as a case study at Sectra ImIT, an Agile Health IT company working with Imaging and IT solutions that is currently in an early phase of introducing metrics in the System Development process. The purpose of this thesis was to investigate and suggest how the organization could use metrics to control and evaluate value creation in the System Development process. It also aimed to provide strategic recommendations to such an organization how they could continue their work with implementing and using metrics. The descriptive and exploratory purpose of this study was realized through unstructured and semistructured interviews with people involved in the process as well as observations. One of the major findings in this thesis is related to a missing feedback loop from defects occurring at customer site to the internal System Development process. Therefore, this study developed and implemented a concept to generate this feedback. The concept builds on defect information that can be used both to generate feedback and statistics for evaluation. The second major finding in this study is related to the identification of barriers to why the organization is not using metrics in teams to control and evaluate the process. Based on these findings, the authors presented several recommendations that should be considered to create a culture where teams are using metrics to learn more about the process. The first recommendation is that the organization should set guidelines among teams of what should, and is desired to be evaluated with focus on information need. Secondly, metrics need to be higher prioritized through directives from management granting team’s resources to manage metrics, which at the same time provides incentives that the organization believe metrics could improve their work. Thirdly, based on the company context, teams should identify metrics based on an information need derived from their prioritizations, changes, decisions and what is currently left unanswered. Finally, metrics should primarily be used to provide means for discussion and provide feedback with focus on trends rather than absolute numbers. / Det huvudsakliga målet för ett godtyckligt företag inom mjukvaruutveckling är att maximera det värde som skapas i varje enskild investering. För att förstärka och snabba upp värdeskapande har Agil mjukvaruutveckling växt i popularitet som en respons mot volatila och osäkra marknader. I en Agil miljö fokuserar grupper på ”lättviktade” arbetsmetoder, kontinuerliga leveranser och kundsamarbeten över det tidigare arbetssättet som bestod av mycket dokumentation och inflexibla processer. Samtidigt har det Agila arbetssättet gjort det svårt för organisationer att kontrollera och utvärdera processen, vilket har resulterat i att organisationer antar att deras Agila process är ideal och välfungerande med avsaknad av belägg för det. Detta examensarbete genomfördes som en fallstudie på Sectra ImIT, ett Agilt företag inom medicinsk teknik med fokus på bildhanteringssystem och IT lösningar. Företaget är i en tidig fas av att undersöka och introducera mätetal i systemutvecklingsprocessen, där syftet med examensarbetet var att utvärdera och föreslå hur organisationen kunde använda mätetal för att kontrollera och utvärdera värdeskapande i processen. Därtill ämnade studien även att ge strategiska förslag på hur företaget i framtiden kan arbeta med att implementera och använda sig av mätetal. Det deskriptiva och explorativa syftet realiserades genom ostrukturerade och semi-strukturerade intervjuer samt observationer med människor som dagligen arbetade inom processen. En iakttagelse var kopplad till avsaknaden av återkoppling mellan de defekter som uppkommer ute hos kund tillbaka till systemutvecklingsprocessen. Detta resulterade i ett koncept som utvecklades och implementerades av författarna med syfte att skapa återkoppling och möjlighet till statistisk utvärdering av processen som helhet. Den andra iakttagelsen berörde ett antal anledningar till varför organisationen inte använder mätetal i teams för att kontrollera och utvärdera processen. Baserat på en analys av dessa presenterar författarna flertalet rekommendationer som företaget borde ta hänsyn till för att skapa en kultur som främjar användandet av mätetal för att skapa ytterligare förståelse för processen. Den första rekommendationen är att organisationen bör diskutera riktlinjer gemensamt för teams gällande vad som anses önskvärt att utvärdera, med fokus på informationsbehov. Därtill bör organisationen uppmana teams till att allokera mer resurser på mätetal, vilket samtidigt ger incitament att det är något företaget tror kan hjälpa teams att bli bättre. Utifrån företagets kontext bör teams själva tillåtas att identifiera mätetal baserat på deras informationsbehov som ett resultat av exempelvis prioriteringar, förändringar, beslut och vad som för tillfället är obesvarat. Slutligen ska mätetal användas i huvudsak som en grund för diskussion och feedback med fokus på trender snarare än att uppnå specifika mål.

As the digitisation of healthcare progresses, there are still problems in terms of usability. With the goal of exploring solutions to these, an email inspired design for an electronic health record system was implemented using modern web technologies. The implementation was then evaluated in a series of usability tests conducted with five orthopaedic surgeons. Participants were asked to perform small tasks on a mocked data set, and the sessions were concluded with debriefing interviews. The focus was on the areas that are new in this design. The results suggest that the general design works, and no critical flaws were identified at this stage. Most of the issues that were found are likely to be solved with more training and experience, but there is still room for improvement. Participants had positive reactions overall, and plenty of feedback was collected regarding areas of improvement and feature suggestions. Due to the limitations of the test, the findings mostly relate to the intuitiveness of the design. To draw stronger conclusions regarding the viability of the design in a real environment, further testing with more data, realistic test tasks and more prerequisite training is necessary. / Digitiseringen inom sjukvården ökar, men det finns fortfarande problem när det kommer till användbarheten av de digitala system som finns på marknaden. Med målet att utforska lösningar på dessa problem implementerades i detta arbete en e-post-inspirerad gränssnittsdesign för ett digitalt journalsystem med hjälp av moderna webb-teknologier. Implementationen utvärderades genom användartester där fem ortopediska kirurger deltog. Deltagarna ombads använda gränssnittet för att utföra små testuppgifter med påhittad patientdata, och sessionerna avslutades med intervjufrågor. Fokuset var på de delar som är nya i den här designen jämfört med redan existerande system. Resultatet visar att det generella upplägget fungerar, och inga kritiska brister upptäcktes i detta stadie. De flesta av problemen som uppdagades kan troligen lösas genom att användarna ges möjlighet till mer träning och får mer erfarenhet, men det finns fortfarande förbättringutrymme. Deltagarna hade positiva reaktioner i allmänhet, och många förslag kring förbättringsområden och önskemål kring utökad funktionalitet samlades upp. På grund av användartestets begränsningar belyser resultaten i detta test mest vilka delar av gränssnittet som är intuitiva eller ej, medan det som är mer intressant för den här typen av dagligen använda system egentligen är huruvida de är effektiva att använda i det dagliga arbetet. För att kunna dra säkrare slutsatser kring om den här designen skulle fungera i riktiga arbetssituationer behövs mer testning med större mängder patientdata, mer realistiska testuppgifter och mer tid för deltagarna att lära sig systemet i förväg.