<p>Electronic Health Record Systems (EHRs) are an important tool for today’s physicians. EHRs (commonly called EMRs in Canada) are used to store, retrieve and leverage patient information to achieve better clinical outcomes for patients. EHRs can also contribute to public policy by helping policy makers track population health data. There are barriers as well as drivers to successful implementation of EHRs. Also, with the introduction of EHRs and their accumulation of patient data physicians face challenges for better extraction and use of data as well as overall management of information within the clinic.</p> <p>This thesis performs a literature review and presents evidence on the barriers and drivers that exist in the area of EHR (Electronic Health Records) implementation in the US. The thesis also includes a survey that tracks responses of primary care physicians in the US. The responses were analyzed to determine key factors impacting EHR implementation and information management. The key factors included workflow, optimization of information technology (IT) resources that include software, hardware assets and trained personnel, and plan for extraction of data. Our research found, among other things, the need to raise awareness among physicians about optimizing clinical workflow, management of information in the EHRs, the need for additional training on the EHRs and, in case of non-urban physicians, the need for improved levels of IT and Internet expertise in the clinic.</p> / Master of Science (MSc)

The impact of Computerized Physician Order Entry (CPOE) on the dependent variables of medication-order compliance and time to first dose of antibiotic was investigated in this quasi-experimental study of a naturally-occurring CPOE intervention. The impact of CPOE on compliance and time to first dose was assessed by comparing measures of these variables from the intervention site and a non-equivalent control before and during intervention phases. Medication orders placed using CPOE were significantly more compliant than paper-based medication orders (p<.001), and first doses of antibiotic ordered using CPOE were delivered significantly faster than antibiotic orders placed using the paper-based system (p<.001). Findings support previous research indicating the positive impact of CPOE on patient safety as well as justify and enable future interventions to increase CPOE adoption and use among physicians. Additionally, data collected in this study will be used to provide behavior-based feedback to physicians as part of CPOE adoption and use intervention strategies to be explored in the forthcoming research. / Master of Science

acase@tulane.edu

Doctor of Philosophy / Computerised Provider Order Entry (CPOE) systems provide clinicians with the ability to electronically enter hospital orders for laboratory tests and services. CPOE is able to integrate with hospital information systems and provide point of care decision support to users thereby making a potentially significant contribution to the efficiency and effectiveness of care delivery. The evidence of the impact of CPOE systems on pathology services is not extensive and insufficient attention has been paid to their effect on organisational and communication processes. This thesis aimed to investigate the implications of CPOE systems for pathology laboratories, their work processes and relationships with other hospital departments, using comparative examinations to identify the tasks they are involved in and the particular needs the laboratories expect to be filled by the new system. This longitudinal study of a CPOE system was carried out over three years using multiple cases from a hospital pathology service based at a large Sydney teaching hospital. Multi-methods using quantitative and qualitative data were employed to achieve triangulation of data, theory and methods. The findings provide evidence of a significant 14.3% reduction of laboratory turnaround times from 42 to 36 minutes when laboratory data for two months were compared before and after CPOE implementation. The findings also reveal changes in the pattern and organisation of information communication, highlighting transformations in the way that work is planned, negotiated and synchronised. These findings are drawn together in a comprehensive organisational communication framework that is highly relevant for developing a contingent and situational understanding of the impact of CPOE on pathology services.

Abstract The 2009 American Recovery and Reinvestment Act has earmarked 27 billion dollars to promote the adoption of Health Information Technologies (HIT) in the US, and to gain access to these funds, providers must document “Meaningful Use” during the care process. While individual HIT use according to lean measures, including meaningful use, is prevalent in the IS literature, few studies have incorporated rich measures to account for the task, the technology, and the user in a team context. This dissertation conceptualizes Team Deep Structure Use of Computerized Provider Order Entry (CPOE) as an IT- enabled coordination mechanism, and Relational Coordination as the inherent ability of clinical teams to coordinate care spontaneously using informal, relationship based mechanisms. IT-enabled and Relational Coordination mechanisms are each evaluated across five maximally different patient conditions to simultaneously examine their impact on our outcome measure, Patient Satisfaction with the clinical care team. The extant literature has established a deep understanding of IT adoption shortly after implementation, yet the literature is silent on the antecedents of IT use according to rich measures well after the shake down phase, a period in which the majority of organizations operate. We incorporate the Adaptive Structuration Theory (AST) constructs of Faithfulness of Appropriation, and Consensus on Appropriation as the focal antecedents of Deep Structure Use of the clinical system by team members. To our knowledge, no prior research has linked these two AST constructs to clinical outcomes through the incorporation of a rich use mediator such as Deep Structure Use of a Health IT. To test our model, we relied on survey responses from 555 physicians, nurses and mid-levels which had cared for 261 patients across five patient conditions, ranging from vaginal birth, to organ transplant, as well as pneumonia, knee/hip replacement and cardiovascular surgery. Our results confirm that the Adaptive Structuration constructs of Faithfulness of Appropriation and Consensus on Appropriation, generate positive and statistically significant path coefficients predicting Team Deep Structure Use of CPOE. We also report differential effects on Patient Satisfaction with the care team resulting from technology use. Results range from a significant positive path coefficient (.285) associated with higher Team Deep Structure Use on combined Pneumonia and Organ Transplant teams, to a significant negative path coefficient (-.174) on cardiovascular surgery teams. As expected, Pneumonia, Organ Transplant and Cardiovascular Surgery teams all reported positive effects on Patient Satisfaction with the care team as a result of higher Relational Coordination scores. For teams caring for patient conditions consistently associated with a shorter length of stay, including vaginal birth and knee/hip replacement, higher reported use of IT- enabled, or Relational Coordination mechanisms, did not result in a significant increase in Patient Satisfaction. This dissertation contributes to the growing Health IT literature, and has practical implications for clinicians, hospital administrators and Health IT professionals. This dissertation is the first to operationalize a rich measure of use of an HIT by clinical teams, and to simultaneously measure the impact of IT enabled and Relational Coordination mechanisms on Patient Satisfaction. Secondly, through the introduction of Adaptive Structuration constructs, our model establishes a methodology for predicting rich, nuanced use in teams well after the initial shake down phase associated with recent HIT implementation. Through the juxtaposition of the impact of IT-enabled and Relational Coordination mechanisms across patient conditions, practitioners can design interventions and adjust the level of resources applied to process improvement accordingly.

Electronic medical records (EMR) and computerized provider order entry (CPOE) are recognized as a means to improve quality of care and patient safety. This research examines factors that contribute to clinician acceptance of an EMR implemented in a pediatric hospital system and applies this knowledge to improve implementation methods to ensure they foster acceptance. A framework for User-Centered Implementation (UCI) was developed based on previous EMR and CPOE, technology acceptance, user-centered design, and change management research. The UCI framework identifies tools from change management and user-centered design and links them to the systems development lifecycle stage(s) at which they can be applied to achieve improved user acceptance. Next, a study examined clinician EMR acceptance in a pediatric hospital system at various points during their EMR implementation which employed a UCI-based methodology. Surveys before and after implementation of each phase examined physician, nurse, and other staff perceptions about the systems usefulness (performance expectancy (PE)) and ease of use (effort expectancy (EE)). Results indicate users had positive perceptions of system ease of use (EE) after implementation. Post-implementation PE ratings were neutral or positive for most users. Pre- and post-implementation regression models indicate the factors that influence PE change over time. Compatibility with clinician work practices was important both before and after implementation. Before implementation, users who perceived a greater need for the system and felt their needs were represented during design had higher expectations of system usefulness. After implementation, system characteristics including how well it supports clinical decision making and how easy it is to use influenced PE. Support provided by super users positively influenced both PE and EE after implementation. Based on these findings, guidelines for using UCI to improve clinician acceptance of EMR are presented. Designing EMR systems that are usable within the clinical work context enables clinicians to focus on the patient, rather than the system. Accomplishing this in practice is difficult given the complexity of EMRs and the dynamic clinical processes they support. This studys results indicate the UCI framework can be effectively applied to EMR implementations to improve the usability, utility, and, consequently, acceptance of these systems.

Doctor of Philosophy / Computerised Provider Order Entry (CPOE) systems provide clinicians with the ability to electronically enter hospital orders for laboratory tests and services. CPOE is able to integrate with hospital information systems and provide point of care decision support to users thereby making a potentially significant contribution to the efficiency and effectiveness of care delivery. The evidence of the impact of CPOE systems on pathology services is not extensive and insufficient attention has been paid to their effect on organisational and communication processes. This thesis aimed to investigate the implications of CPOE systems for pathology laboratories, their work processes and relationships with other hospital departments, using comparative examinations to identify the tasks they are involved in and the particular needs the laboratories expect to be filled by the new system. This longitudinal study of a CPOE system was carried out over three years using multiple cases from a hospital pathology service based at a large Sydney teaching hospital. Multi-methods using quantitative and qualitative data were employed to achieve triangulation of data, theory and methods. The findings provide evidence of a significant 14.3% reduction of laboratory turnaround times from 42 to 36 minutes when laboratory data for two months were compared before and after CPOE implementation. The findings also reveal changes in the pattern and organisation of information communication, highlighting transformations in the way that work is planned, negotiated and synchronised. These findings are drawn together in a comprehensive organisational communication framework that is highly relevant for developing a contingent and situational understanding of the impact of CPOE on pathology services.

A presente dissertação descreve os testes psicológicos mencionados nos textos pedagógicos publicados na Revista do Ensino, entre os anos de 1939 e 1971, e no Boletim do Centro de Pesquisas e Orientação Educacionais, entre os anos de 1947 e 1966, ambos produzidos no Rio Grande do Sul. A análise histórica a partir da leitura atenta dos documentos permitiu a identificação e a descrição dos testes veiculados nos periódicos. O enfoque temático central desta pesquisa encontra-se na segunda parte deste trabalho, privilegiando a descrição dos testes, seus objetivos, seus modos de aplicação, correção e significação. O estudo argumenta, na sua primeira parte, que as ideias psicológicas dos testes já se encontravam presentes nos primeiros textos analisados, ainda que de forma simplificada e conectada intimamente aos saberes da medicina social, da psicologia experimental, da educação dos excepcionais e da higiene mental. No período examinado, os Testes ABC de Lourenço Filho e o Teste da Figura Humana de Florence Goodenough se destacaram como os instrumentos mais citados nos periódicos. A presente dissertação inclui-se entre os esforços que apontam a presença e a circulação dos testes psicológicos na esfera da escolarização no Rio Grande do Sul. / The present dissertation aims to describe the psychological tests mentioned in the pedagogical texts that have been published in the Revista do Ensino, between the years of 1939 end 1971, and in the Boletim de Centro de Pesquisas e Orientações Educacionais, between the years of 1947 and 1966, both of them produced in Rio Grande do Sul. The historical analysis based on the attentive reading of the documents allowed do identify and describe the tests that have been published in the periodicals. The thematical focus of this research is displayed in the second part of this work, showing primarily the description of the tests, their aims, their possible ways of application, correction and sigification. The study argues, in his first part, that the psychological ideas of the tests are already found in the first analysed texts, even if in a simplified way and deeply conected with the knowledges of social medicine, of experimental psychology, of the education of the exceptional individuals and of mental care. In the examinated period, the Testes ABC of Lourenço Filho and the Teste da Figura Humana of Florence Goodenough have been the most mentioned in the periodicals. The present dissertation is included among the efforts of trying to indicate the presence and the circulation of the psychological tests in the scope of education in Rio Grande do Sul.

A presente dissertação descreve os testes psicológicos mencionados nos textos pedagógicos publicados na Revista do Ensino, entre os anos de 1939 e 1971, e no Boletim do Centro de Pesquisas e Orientação Educacionais, entre os anos de 1947 e 1966, ambos produzidos no Rio Grande do Sul. A análise histórica a partir da leitura atenta dos documentos permitiu a identificação e a descrição dos testes veiculados nos periódicos. O enfoque temático central desta pesquisa encontra-se na segunda parte deste trabalho, privilegiando a descrição dos testes, seus objetivos, seus modos de aplicação, correção e significação. O estudo argumenta, na sua primeira parte, que as ideias psicológicas dos testes já se encontravam presentes nos primeiros textos analisados, ainda que de forma simplificada e conectada intimamente aos saberes da medicina social, da psicologia experimental, da educação dos excepcionais e da higiene mental. No período examinado, os Testes ABC de Lourenço Filho e o Teste da Figura Humana de Florence Goodenough se destacaram como os instrumentos mais citados nos periódicos. A presente dissertação inclui-se entre os esforços que apontam a presença e a circulação dos testes psicológicos na esfera da escolarização no Rio Grande do Sul. / The present dissertation aims to describe the psychological tests mentioned in the pedagogical texts that have been published in the Revista do Ensino, between the years of 1939 end 1971, and in the Boletim de Centro de Pesquisas e Orientações Educacionais, between the years of 1947 and 1966, both of them produced in Rio Grande do Sul. The historical analysis based on the attentive reading of the documents allowed do identify and describe the tests that have been published in the periodicals. The thematical focus of this research is displayed in the second part of this work, showing primarily the description of the tests, their aims, their possible ways of application, correction and sigification. The study argues, in his first part, that the psychological ideas of the tests are already found in the first analysed texts, even if in a simplified way and deeply conected with the knowledges of social medicine, of experimental psychology, of the education of the exceptional individuals and of mental care. In the examinated period, the Testes ABC of Lourenço Filho and the Teste da Figura Humana of Florence Goodenough have been the most mentioned in the periodicals. The present dissertation is included among the efforts of trying to indicate the presence and the circulation of the psychological tests in the scope of education in Rio Grande do Sul.

A presente dissertação descreve os testes psicológicos mencionados nos textos pedagógicos publicados na Revista do Ensino, entre os anos de 1939 e 1971, e no Boletim do Centro de Pesquisas e Orientação Educacionais, entre os anos de 1947 e 1966, ambos produzidos no Rio Grande do Sul. A análise histórica a partir da leitura atenta dos documentos permitiu a identificação e a descrição dos testes veiculados nos periódicos. O enfoque temático central desta pesquisa encontra-se na segunda parte deste trabalho, privilegiando a descrição dos testes, seus objetivos, seus modos de aplicação, correção e significação. O estudo argumenta, na sua primeira parte, que as ideias psicológicas dos testes já se encontravam presentes nos primeiros textos analisados, ainda que de forma simplificada e conectada intimamente aos saberes da medicina social, da psicologia experimental, da educação dos excepcionais e da higiene mental. No período examinado, os Testes ABC de Lourenço Filho e o Teste da Figura Humana de Florence Goodenough se destacaram como os instrumentos mais citados nos periódicos. A presente dissertação inclui-se entre os esforços que apontam a presença e a circulação dos testes psicológicos na esfera da escolarização no Rio Grande do Sul. / The present dissertation aims to describe the psychological tests mentioned in the pedagogical texts that have been published in the Revista do Ensino, between the years of 1939 end 1971, and in the Boletim de Centro de Pesquisas e Orientações Educacionais, between the years of 1947 and 1966, both of them produced in Rio Grande do Sul. The historical analysis based on the attentive reading of the documents allowed do identify and describe the tests that have been published in the periodicals. The thematical focus of this research is displayed in the second part of this work, showing primarily the description of the tests, their aims, their possible ways of application, correction and sigification. The study argues, in his first part, that the psychological ideas of the tests are already found in the first analysed texts, even if in a simplified way and deeply conected with the knowledges of social medicine, of experimental psychology, of the education of the exceptional individuals and of mental care. In the examinated period, the Testes ABC of Lourenço Filho and the Teste da Figura Humana of Florence Goodenough have been the most mentioned in the periodicals. The present dissertation is included among the efforts of trying to indicate the presence and the circulation of the psychological tests in the scope of education in Rio Grande do Sul.