The rise in both ageing and chronic disease populations has highlighted a pressing demand for better access to quality healthcare at home. Meanwhile, studies have shown that home-based treatments for older patients as a substitute for hospital care can produce better clinical outcomes and reduce healthcare expenditure. However, there remains a considerable question relating to the low adoption rate of home telehealthcare technologies due to a lack of robust evidence for their cost-effectiveness. In light of both the epoch-making advancements in smartphone-centric technologies and the pervasive uptake of smartphones, we set up as our core objective the cost-effective design of a real-time home healthcare telemonitoring system based on mobile cloud computing. Our second objective was to develop a simulation environment to produce robust evidence for cost-effectiveness of a telemonitoring system so as to explore technology choices in different settings prior to moving to full-scale trials on a more scientific basis. A proof-of-concept system consisting of three main monitoring functions, namely vital sign, safety (for fall detection) and movement pattern monitoring (for real-time indoor location tracking), was developed based on a smartphone. With the exception of vital sign monitoring design which was not regarded as a search problem, the results of the other two were promising with sensitivity and specificity for successfully detected falls and recognised non-fall activities being both 95.5% and an average estimation error of 0.47 metres for real-time indoor location tracking. A large number of patients and their activities of daily living, as well as real-world like telehealthcare scenarios involving a number of different stakeholders and telemonitoring interventions, were modelled and created through simulations. The cloud-based components of our proposed telemonitoring system were also modelled and simulated together with our proposed forward-looking unused capacity-based auto scaling (FLUCAS) algorithm to enhance system performance and scalability and reduce the costs. Economic evaluations of our proposed system were conducted based on a comparative cost-effectiveness analysis approach and the results of our simulation experiments. Although exploratory, this study not only offers some insight into the great potential of smartphone-centric technologies in support of a cost-effective design of real-time home healthcare telemonitoring, but also provides justifiable evidence for cost-effectiveness of telemonitoring.

The sociology and economics of the conduct of international e-health technology transfers (IeTTs) is examined. Most African countries are perennial recipients with variations in their domestic e-health utilisation, development and implementation. We identify, explore, and demonstrate how complex and interlinked global, continental, national and subnational actions and institutions condition their national e-health implementations. Multidisciplinary literatures are from national e-health implementations, national innovation system (NIS) interactive learning, international technology transfers, global development and globalisation. Methodically, a unique combination of middle-range and moderate Science and Technology Studies constructivism, NIS institutionalism and Deleuzian poststructuralist narrative is employed. The conduct of IeTTs is characterised by technological path dependency, history, complexity, power, politics, multiple identities, self-interests and contestations in complex global and transnational interactions. Recipients‘ exercises of National Agency mirror their varied domestic technology acquisition dynamics and trajectories. Successful transfers are institutionally conditioned by interactions of global geopolitics, fragmented continental governance and national reticence. Agential asymmetry that results, accounts for why most recipients are variably struggling in their technology acquisitions. The exercise of National Agency is paramount. National economic size and maturity of extant national innovation capacity can determine if a recipient can acquire domestic e-health innovation and industrial competences. Actions taken by National governments, can strategically determine if technologies are accumulated and technical knowledge assimilated, for addressing the challenges of technology inappropriateness, incompatibilities and obsolescence encountered during subnational utilisations. We contend that implementing a national e-health infrastructure is a long-term and large-scale institutional engineering endeavour. Cumulative advantage explains difference between Schumpeter and Schumacher on e-health technology design and production. A Schumpeterian domestic industrial model of hi-tech e-health technology development, rather than a cosmopolitan Schumacher consumerist one, is proposed. Whilst, appreciating that Schumacher on incremental accumulation and assimilation from small-scale technological implementations can be instrumental. Uniquely, we identify that global geopolitical contention between global west and east economies and competitive global markets and global technoeconomic changes can either condition scale and depth of domestic acquisition. Nevertheless, these conditions and events have historically and contemporaneously shaped global e-health innovations. In a Schumpeterian evolutionary sense, Satcom technologies that powered e-health services in the past are now being substituted by mobile ones. This technological transition is bringing about a convergence of consumer electronics (i.e. Smartphones) and lifesciences industries, driven by a combinatorial biomedical, telecommunication and computing e-health innovations. With these findings, an innovation-based macro-societal perspective is proposed for studying e-health implementation, as opposed to the prevalent information based microbehavioural studies. Further contributions to academia and policy are made to ICT4D, Global Health and m-health practices. Policy recommendations are made to national, continental and global institutions on how to foster national technology acquisitions. Recipients are encouraged to learn from incremental domestic e-health implementations in global technology frontiers. Their share in intellectual property rights accruing from global-subnational e-health coinnovations must be repatriated. We conclude by proposing a global collaboration framework to guide and to foster cooperation amongst those involved in the conduct of IeTTs. Symmetry – an alignment of vertical hierarchical and diffuse horizontal complex sociotechnical interactions, though, not as the implied flat, circumscribed and cyclical dynamics of actor network theory, is proposed. So, an alignment of the constitutive diverse and competing interests and identities, is deemed strategic, to foster domestic accumulations and assimilations.

This research is characterised by its overlap of research from management and healthcare. This research is an attempt to contribute to the existing body of knowledge on the linkages between three multidisciplinary research themes; healthcare management concepts, information and communication technology (ICT) and knowledge management (KM). The objective of this research is to examine the feasibility of incorporating the KM paradigm in healthcare. This research discusses whether it would be beneficial for healthcare institutions (HIs) to adopt the KM paradigm so as to facilitate effective decision-making in the context of healthcare delivery. This research contends that the key to success of healthcare in the twenty first century is an effective integration of technology with the human clinical decision-making process. It is therefore important to develop a conceptual KM health framework that encompasses technological, organisational and managerial perspectives. The research design, guided by a qualitative philosophy, was inductive in nature and used the case study methodology for accomplishing the research objectives. Empirical data was gathered via a main case. The findings from the main case, in conjunction with inputs from the literature review, formed an iterative process. The analysis of the collected data resulted in a first level conceptual KM framework for Healthcare organisations. Data was then gathered from five additional case studies to (1) validate the findings obtained from the main case and (2) to carry out a cross-case analysis. Data was collected from personnel at the five cases by way of structured and semi-structured interviews, observations, archival records, telephone and virtual interviews. The analysis of the data obtained from the five cases lead to a revision of the first conceptual KM framework, resulting in a revised (and final) KM-Healthcare framework, complemented by a user guide which included a structured "walk-through" for Healthcare institutions.

Background Research has shown that healthcare organisations can cause harm to patients, much of which is avoidable, and there is reliable evidence to suggest that this harm is a widespread and recurring phenomena (Institute of Medicine 1999; Department of Health 2000; Leape et al 2002; de Vries et al 2008; Longtin et al 2009; Jha et al 2010). Encouraging patients to take an active role in their own healthcare was identified in the landmark patient safety publication ‘To Err is Human’ (Institute of Medicine 2000) as a vital factor in the quest to improve patient safety. It has since been contended that if patients were involved in their healthcare they could help to further reduce opportunities for accidents and errors during the course of their care (Vincent and Coulter 2002; Koutantji et al 2005; Weingart et al 2005; Unruh and Pratt 2006; Davis et al 2007). More recently, there has been growing interest in the development and use of interventions to promote and support patients’ roles in securing their own safety in healthcare contexts (Hall et al 2010; Longtin et al 2010; Peat et al 2010; Doherty and Stavropoulou 2012; Vaismoradi et al 2014). Aims The broad aim of this study is to explore the extent to which patients are involved in attempts to improve their own healthcare safety through enrolment in an enhanced recovery after surgery (ERAS) programme. Recognising that patient safety is just one aspect of the ERAS programme theory, this research evaluates those elements of the programme that see patients taking a role in their own healthcare safety. This is achieved by considering in realist terms the mechanisms of effect by which patients might contribute to their healthcare safety and investigating the conditions and circumstances (contexts) that are required to enable this involvement. The overall aim of this research is to seek out regularities in the patterns of these contexts and mechanisms which result in patient involvement in patient safety. The emerging theory will explain implementation variations, and the experiences of the programme participants in the different cases will provide an opportunity to make comparisons with initial programme theories, the objective being to better understand when and why patient involvement in patient safety works in an ERAS programme. Methods The underpinning methodological framework for this research is realist evaluation (Pawson and Tilley 1997), which is a technique concerned with exploring the interaction among context, mechanism and outcome, based on the realist principle of generative causation. This study uses an in-depth multiple case study approach, with each of the three surgical units under study purposively selected to represent involvement in the ERAS programme. To capture the complex and dynamic nature of the programme under investigation, the study draws on a wide range of empirical data sources, methods and materials, including ethnographic observations, semi-structured interviews and document analysis. Taking ‘early mobilisation’ as a tracer outcome, the study examines the mechanisms and contexts involved in programme outcomes in relation to patient involvement in patient safety. The first stage of the enquiry involves eliciting and formalising the programme theories relating to patient involvement in patient safety in an ERAS programme which are then articulated in conjectured context-mechanism-outcome configurations (CMO) terms. The next stage involves collecting data that will allow interrogation of these hypotheses, comparing the programme’s intentions with case study data of actual practice that occurred and the views and experiences of key stakeholders, including patients and nursing staff. This is followed by cross case comparisons which attempt to determine how the same mechanisms played out in different contexts. Key findings Overall, the findings show that there are many contextual factors relating to the successful outcomes of the programme theories postulated. The key findings of this study demonstrate that successful patient involvement in patient safety related elements of an ERAS programme requires that: ward staffs are aligned with the programme objectives; that patients’ expectations for their post-operative recovery are managed prior to surgery and the underlying rationale for their care is understood and; in the post-operative period patients’ enrolment in the programme is sustained and reinforced by ward based staff. The study also demonstrates how differences in the implementation of ERAS across the study sites, support for early mobilisation and individual patient differences (for example emotional status and operation type) were consequential for the outcomes of the programme theory. Conclusion This thesis sits at the interface of a number of health policy and quality improvement trends including patient involvement, patient safety, standardisation, patient centred care, co-production and the growing interest in healthcare with the implementation and embedding of interventions. The aspirations of policy and programme documentation to ‘empower’ patients to take a more active role in their care also proved more complex in reality. The study highlights the tensions between achieving a quality standard and patient centred care and how the approach to postoperative care in the three different case study sites shaped nurses’ willingness to adapt the programme and support patient involvement. The main areas for consideration from this study include the importance of the role of healthcare staff in attempts to involve patients in patient safety, along with the tensions between standardisation of care versus the aspirations of providing person-centred, individual care for patients. This is considered in relation to the ongoing standardisation of healthcare through an increasing reliance on protocols and pathways, such as the ERAS programme.

Health management information systems (HMIS) are implemented in less developed countries (LDCs) with the expectation that they will contribute to improving primary health care (PHC) delivery. Information generated through these systems is conceived as an imperative for better decision making processes and strengthening accountability arrangements that underpin the delivery of PHC. Despite strong rhetoric and significant investments to support these systems, most HMIS implementation in LDCs face challenges of poor data quality and weak accountability arrangements that limit their impact on health status. This constitutes a divergence from the instrumentality of predetermined indicators measuring health status performance that do not necessarily reflect the complex reality underlying how poor communities define their health priorities. We therefore highlight that accountability for performance management may indeed detract from the objective of improving the health of the poor and needs to be understood more broadly. This study illuminates the challenges and potential of HMIS implementation through accountability arrangements that are socially embedded in institutions, interactions and interpretations of global and local actors. As such, our primary research question is, “To what extent can HMIS improve accountability arrangements of PHC delivery?” Employing an interpretivist research methodology, we provide perceptions of how interactions between citizens, service providers, bureaucratic and political agents dynamically construct, contest and navigate accountability arrangements underpinning the provision of health care. This understanding has hitherto been limited in the HMIS literature. As a central theme in ICT for Development literature, illuminating these interactions furthers our understanding regarding the potential of HMIS in improving the lives of the poor. National governments, donors and HMIS practitioners will benefit from the practical insights derived from this study especially in relation to reconceptualising HMIS analysis to incorporate contextual and developmental notions of PHC. With relatively limited HMIS research, Northern Nigeria as the empirical context of this study also constitutes a useful contribution to the body of knowledge.

This thesis is a result of a research project that examines the Information Systems strategy of the National Health Service (NHS). The researcher followed the process of implementing a Primary Service Provision (PSP). PSP is an initiative by the NHS Information Authority (NHSIA) to develop and establish a National Programme for Information Technology (NPfIT)—a means of providing a useable electronic health record nationally to the UK. Five case studies are presented in the thesis, containing: 1. Two primary care facilities; 2. Three secondary care facilities; These cases were developed as a result of studying the internal processes, decision and support paths applied individually in the NHS. The research approach adopts qualitative and interpretative analysis that includes longitudinal case studies. This multiple case study approach has an embedded design incorporating the components of work business processes as subunits to enhance insight. Data was collected predominantly from interviews supported by archive material, documents, and direct observation. Overlapping cross case, and within case analysis was undertaken, using Activity Records, Strategic Choice Analysis, and concepts supported by various researchers in the past (Avgerou & Cornford, 1993; Davenport, 1993; Eisenhardt, 1989; Galliers, 1991). While it might be possible for similar processes to result in different solution when adopted in another research context, in these seven cases quite different approaches were taken. The Thesis concludes that while the core processes were the same across the cases, the following issues combined together to lead to quite different approaches in each case: 1. The detail of the IS strategic processes; 2. The variation in the contexts; 3. The logic of the decision process as they evolved; and 4. The view of the actors involved. The researcher is of a strong belief that as time progresses and experience is gained and the situation with NPfIT evolves, the various actors would change their views towards IS strategy. This could result in changes in the overall NHS IS business model and healthcare delivery process support. This assumption, however, could be affected by the appearance of very little transfer of knowledge—across different parts of the NHS—regarding past experience with IS implementation. The author argues that NPfIT mainly serves to diffuse information and communication technologies in the NHS. As a result the NPfIT is changing the way by which the NHS competes and meets the needs of it patients, the business model and the value-creating processes. New opportunities are also taking place introducing new healthcare delivery processes and modifying the existing processes.

Social media has had an impact on how patients experience healthcare. Through online channels, patients are sharing information and their experiences with potentially large audiences all over the world. While sharing in this way may offer immediate benefits to themselves and their readership (e.g. other patients) these unprompted, self-authored accounts of illness are also an important resource for healthcare researchers. They offer unprecedented insight into understanding patients’experience of illness. Work has been undertaken through qualitative analysis in order to explore this source of data and utilising the information expressed through these media. However, the manual nature of the analysis means that scope is limited to a small proportion of the hundreds of thousands of authors who are creating content. In our research, we aim to explore utilising text mining to support traditional qualitative analysis of this data. Text mining uses a number of processes in order to extract useful facts from text and analyse patterns within – the ultimate aim is to generate new knowledge by analysing textual data en mass. We developed QuTiP – a Text Mining framework which can enable large scale qualitative analyses of patient narratives shared over social media. In this thesis, we describe QuTiP and our application of the framework to analyse the accounts of patients living with chronic lung disease. As well as a qualitative analysis, we describe our approaches to automated information extraction, term recognition and text classification in order to automatically extract relevant information from blog post data. Within the QuTiP framework, these individual automated approaches can be brought together to support further analyses of large social media datasets.

The NHS is providing patients with access to summaries of their individual health records, so that they can understand and manage their conditions more effectively. At the same time, the government is encouraging patients to be more involved in the decisions made about their direction of care, as evidence shows that outcomes improve if decision-making is shared. As the Internet grows, people are using it as a major source of health information. However, anybody can post information to the Internet, and there is no guarantee that it is reliable, accurate, based on research, or relevant. Therefore, people searching online for health information, using generic search engines, are at risk of finding information that may have a detrimental effect on their health and wellbeing. The aim of this research is to produce a model of a multi-approach evidence-based, post-diagnosis support system for patients and carers in England. The literature review carried out by the author identified 300 papers which looked at both the importance of patient participation in decision-making, and the issues with finding and using health information for patients and carers, but not together in the same research. While much has been written about evidence based practice for health professionals, there is a gap in the research about evidence-based patient choice and information service provision and skills for the general public. This is an issue for health professionals because patients are being actively encouraged to participate in the choices made about their treatment, but while there is evidence demonstrating the effectiveness of patient participation, there is no evidence to say that they have adequate access to information and the skills to use it. Health services need to know if there is appropriate information support for the general public, otherwise there is a risk that patients will not have the right information to help them make the best choice. To assess the information-seeking behaviour of the general public, a mixed-study analysis was performed using quantitative and qualitative surveys, and 139 responses were collected and analysed. The population included people suffering from Alzheimer’s disease and their carers. The evidence and the survey results confirmed that people do want to make decisions with their doctor, and that they do search for information, but do not always find what they are looking for. They said that they would value librarian support and information skills training, but would also find an all-encompassing consumer health information web-site useful. A consumer health information literacy framework was developed based on the existing SCONUL Seven Pillars of Information Literacy framework and the five steps to evidence based practice concept. This framework provided the foundation for the design and development of COCO, an innovative model to facilitate access to high quality consumer health information using existing NHS online information products combined with the information skills of public and medical librarians. The innovations of COCO are that it focuses on the whole population, supports those who are and are not computer literate, creates an opportunity for collaboration within the library sector, and builds on existing NHS online resources rather than creating new ones. COCO provides people with a central access point to reliable and relevant online consumer health information to help them make informed decisions about their care pathway. The collaborative element of the model ensures that is accessible to everyone, without incurring significant costs to public services. The main output from this research synthesis, is an original needs-based model (COCO), designed to simplify the consumer health information-seeking process for the general public, enabling them to access the right information to fulfil their information needs and help them make evidence-based treatment decisions with their doctors. The design of COCO was reviewed, validated and improved using structured opinions of experts in consumer health information, evidence based practice, information literacy, and information technology. Real-life consumer scenarios were used to manually test COCO against free text searches in Google. The search results from COCO and Google were analysed and compared using six validation metrics. This demonstrated the efficiency of COCO in providing significantly better quality information relevant to patients and carers, compared to Google. A mock-up of the final design and search results of COCO were then prepared, along with recommendations for future research.

Background: Much social network analysis in health related research has focused on the impact of social networks in the genesis of long term conditions and associated inequalities. However, there has been little research on the role of social networks in the management of such conditions. This is significant at a time when increasing policy emphasis is placed on individual self-care and assumptions are often made about social support, and familial support in particular. The management of chronic illness is complex involving the interplay of personal and contextual factors and comprised of a number of daily activities which include the ongoing negotiation of management into existing roles and the degree of individual engagement with self-management. Little is known about how these aspects interact to shape and influence management, what constitutes a social network for individuals with long term conditions and whether this changes over time.Methods: This study was embedded within the Whole Systems Informing Self-management Engagement (WISE) randomised control trial. It used a longitudinal qualitative design with initial face to face in-depth interviews, telephone follow-ups over a year and final face-to-face interviews where sociograms were also used to elicit network structure.Results: The findings suggest that who is in the social network, and the types of relationships which are present, influence how management practices are framed and the extent to which they are engaged with. Resources available to an individual through the network support, or undermine, engagement and changed over time. Networks included family, friends, GP, nurses and companion animals. The amalgamation of the different types of relationships that constitute the social networks are characterised by three typologies; the family focused network, the friend focused network and the health care professional focused network. These network types reflected where support was sought in times of crisis. In the absence of 'typical' sources accounts highlighted the substitutability of network members which was often narrowly sought from key individuals. Changes in illness management, either positive or negative, were framed around critical moments as they challenged existing norms of practice and involved significant network members. Further, co-morbid conditions placed an additional complexity to management and priorities were shaped by the recursive relationship with health services which seemingly influences patients' orientation in becoming either active assessors of health care or less engaged through being overwhelmed. Conclusions: This thesis challenges the notion of 'self'-management as an individual construct as many of the practices of illness management involved the support and/or negotiation of roles with others. Critical moments are a key point where normalised management practices are challenged and have particular relevance for future interventions which could foster these critical points to facilitate such changes in routines. Interventions and education need to reflect this wider setting in which chronic illness management occurs for the practices of management to become normalised into everyday routines.

Data quality is one of many challenges experienced in electronic healthcare (e-health) services in South Africa. The collection of data with substandard data quality leads to inappropriate information for health and management purposes. Evidence of challenges with regard to data quality in e-health systems led to the purpose of this study, namely to prioritise data quality challenges experienced by data users of e-health systems in South Africa. The study followed a sequential QUAL-quan mixed method research design to realise the research purpose. After carrying out a literature review on the background of e-health and the current status of research on data quality challenges, a qualitative study was conducted to verify and extend the identified possible e-health data quality challenges. A quantitative study to prioritise data quality challenges experienced by data users of e-health systems followed. Data users of e-health systems in South Africa served as the unit of analysis in the study. The data collection process included interviews with four data quality experts to verify and extend the possible e-health data quality challenges identified from literature. This was followed by a survey targeting 100 data users of e-health systems in South Africa for which 82 responses were received. A prioritised list of e-health data quality challenges has been compiled from the research results. This list can assist data users of e-health systems in South Africa to improve the quality of data in those systems. The most important e-health data quality challenge is a lack of training for e-health systems data users. The prioritised list of e-health data quality challenges allowed for evidence-based recommendations which can assist health institutions in South Africa to ensure future data quality in e-health systems. / School of Computing / M. Sc. (Computing)