The management process of chronic diseases is longitudinal in nature. Patient records in electronic format provide information at the point of care and support decision-making processes. In our research, we analyzed the clinical pragmatics of Chronic Disease Management (CDM) and formulated a knowledge model to develop Ontology-based EMR. Our research involved knowledge abstraction, knowledge modeling, and ontology engineering. We applied the Knowledge Management approach to knowledge sources including medical literature, the Chronic Care Model (CCM), CPR Ontology and HL-7 RIM. We studied CDM in detail to abstract conceptual knowledge involved in the process of CDM. The abstracted knowledge was modeled into a formal model called CD-EMR Model. We adapted Methontology and developed an OWL-based ontology from the CD-EMR Model. We evaluated the ontology by instantiating longitudinal clinical cases of chronic diseases. CD-EMR ontology allows (a) computerization of longitudinal patient records, (b) semantic interoperability, and (c) reasoning for clinical decision support.

In 2002 federal funds, known as the Primary Care Health Transition Fund (PCHTF) were transferred to the provinces to experiment with different models of health services delivery in primary care. The Northern Health Authority used the fund to implement a Chronic Disease Management Community Collaborative using the Institute for Healthcare Improvement Breakthrough Series and the British Columbia (B.C.) Expanded Chronic Care Model. Included in the Chronic Care Model is an information systems component that enables a population-based approach using guidelines and data to plan, organize, monitor and deliver care for patients with chronic illnesses. In British Columbia a secure web based system, known as the Chronic Disease Management (CDM) Toolkit was developed by the Ministry of Health and made accessible to all physicians in the province to facilitate CDM by collaboratives and individual general practitioners (GPs). Technology acceptance is a mature concept in the information systems literature, and models of technology acceptance are important in health care with the increasing deployment of information systems to support clinical and management work processes. Understanding what variables influence clinicians to use appropriate technology could promote the diffusion of technology in health care. The Unified Theory of Acceptance and Use of Technology (UTAUT) is a recent (2003) model that consolidates eight models of technology acceptance that are prominent in the information systems literature. The UTAUT analysis revealed that social influence, usefulness, and facilitating conditions are important variables for the acceptance of new technology. With some adaptations to fit the health care context, the UTAUT was found to be an effective tool to measure CDM Toolkit acceptance in the Northern Health Authority. The field observations highlighted salient issues not captured by the UTAUT, including security certificate implementation, access and confidentiality, physician participation, data entry, flow sheets, infrastructure and training.

Telehealth has great potential for providing timely and comprehensive care to community-dwelling older adults while reducing their barriers to healthcare access. The purpose of this study is to understand how older adults with chronic diseases access healthcare services in their community and evaluate the impact of telehealth on access to care from a self-reported survey conducted in British Columbia. About a quarter of older adult participants reported barriers to healthcare access in their community. Participants frequently reported financial barriers to healthcare access regardless of telehealth use. In addition, telehealth users more frequently reported a lack of necessary healthcare services in their community and physical barriers to access to care. Although the findings did not demonstrate a significant difference in access to care between telehealth users and nonusers, telehealth was identified as a meaningful care delivery tool for older adults with barriers to healthcare access. Further efforts are needed to implement a valid tool for ongoing evaluation and optimization of telehealth and integrate telehealth into clinical and community programs to reduce physical and financial barriers to healthcare access for community-dwelling older adults with chronic illnesses. / Graduate

Full service family physicians in British Columbia (BC) are claiming financial incentives in return for providing enhanced care for patients with chronic diseases. These same physicians are also being actively encouraged to adopt electronic medical record systems (EMRs) with an expectation that their adoption will, among other things, aid in improved chronic disease management (CDM). Indeed, both incentives and clinical information systems have been demonstrated in the literature to be crucial components in effective CDM programs. However, within BC little evidence is available that demonstrates whether EMR adoption is in fact associated with improved provision of CDM services. Furthermore, it is not well understood how the CDM incentive program affects a family practice’s adoption of CDM-related EMR functionality. Through a mixed methods study the relationship between EMR adoption and CDM incentives in a small family practice is explored. Additionally, an audit and feedback intervention is used to test the hypothesis that both incentive use and EMR adoption can simultaneously be improved. Results of the study suggest that the presence of an EMR may not guarantee improvements in delivery of incentivized CDM services; that the incentive program has limits in its ability to promote adoption of CDM-related EMR features; and, that a program of audit and feedback may promote improvements in aspects of EMR adoption and incentive utilization. / Graduate / 0723 / 0769

No description available.

Financial incentives offered by payers to health care providers and patients have been identified as a key mechanism to lower costs while improving quality of care. How to effectively design incentive programs that can align the varying objectives of health care stakeholders, as well as predict programs' performance and stakeholders' decision response is an unresolved research challenge. The objective of this study is to establish a novel approach based on multiscale decision theory (MSDT) that can effectively model and efficiently analyze such incentive programs, and the complex health care system in general. The MSDT model captures the interdependencies of stakeholders, their decision processes, uncertainties, and how incentives impact decisions and outcomes at the payer, hospital, physician, and patient level. In the first part of this thesis, we study the decision processes of agents pertaining to the investment and utilization of imaging technologies. We analyze the payer-hospital-physician relationships and later extend the model to include radiologist and patient as major stakeholders in the second part of this thesis. We focus on a specific incentive program, the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs). The multi-level interactions between agents are mathematically formulated as a sequential non-cooperative game. We derive the equilibrium solutions using the subgame perfect Nash equilibrium (SPNE) concept and the backward induction principle, and determine the conditions under which the MSSP incentive leads to the desired outcomes of cost reduction and quality of care improvements. In the third part of this thesis, we study the multi-level decision making in chronic disease management. We model and analyze patients' and physicians' decision processes as a general-sum stochastic game with perfect information and switching control structure. We incorporate the Health Belief Model (HBM) as the theoretical foundation to capture the behavioral aspect of agents. We analyze how incentives and interdependencies affect patients' engagement in health-promoting activities and physicians' delivery of primary care services. We show that a re-alignment of incentives can improve the effectiveness of chronic disease management. / Ph. D.

This dissertation proposes principles for the design of ubiquitous health monitoring applications that support reflection and learning in context of diabetes management. Due to the high individual differences between diabetes cases, each affected individual must find the optimal combination of lifestyle alterations and medication through reflective analysis of personal diseases history. This dissertation advocates using technology to enable individuals' proactive engagement in monitoring of their health. In particular, it proposes promoting individuals' engagement in reflection by exploiting breakdowns in individuals' routines or understanding; supporting continuity in thinking that leads to a systematic refinement of ideas; and supporting articulation of thoughts and understanding that helps to transform insights into knowledge. The empirical evidence for these principles was gathered thought the deployment studies of three ubiquitous computing applications that help individuals with diabetes in management of their diseases. These deployment studies demonstrated that technology for reflection helps individuals achieve their personal disease management goals, such as diet goals. In addition, they showed that using technology helps individuals embrace a proactive attitude towards their health indicated by their adoption of the internal locus of control.

Submitted by JOSIANE SANTOS DE OLIVEIRA (josianeso) on 2018-09-24T18:58:13Z No. of bitstreams: 1 Emerson Butzen_.pdf: 7216894 bytes, checksum: 2d8c31ef74b3d53d626a08f772032736 (MD5) / Made available in DSpace on 2018-09-24T18:58:13Z (GMT). No. of bitstreams: 1 Emerson Butzen_.pdf: 7216894 bytes, checksum: 2d8c31ef74b3d53d626a08f772032736 (MD5) Previous issue date: 2018-04-26 / UNISINOS - Universidade do Vale do Rio dos Sinos / O cenário contemporâneo relativo às doenças crônicas não transmissíveis (DCNTs) é desafiador. De acordo com dados do último relatório da Organização Mundial da Saúde (OMS), no contexto mundial, 38 milhões das mortes são consequência de tais doenças. Até 2030 a previsão é que esse número aumente para 52 milhões. Nesse sentido, o acesso à internet e a proliferação de dispositivos móveis, como é o caso dos smartphones, são ferramentas que facilitam o controle e o acompanhamento autônomo de pacientes. Além disso, os sistemas sensíveis ao contexto se referem a soluções transparentes para coleta de dados de usuários. Eles permitem a identificação de hábitos cotidianos dos indivíduos, o que pode ser decisivo no tratamento de doenças. Já o perfil dinâmico é a criação e a manutenção automática com base em informações e atividades do usuário conforme o tempo (VALMORBIDA; BARBOSA, 2014). Assim partir dos contextos detectados, definem-se perfis, e a conversão entre os dois fornece recomendações de recursos personalizados ao paciente. Considerando este conjunto de informações, define-se a questão de pesquisa que orienta a construção deste estudo: como seria um modelo baseado na Computação Ubíqua que permitisse o gerenciamento de perfis dinâmicos orientados ao acompanhamento de pacientes de DCNTs? Além do auxílio no controle das doenças, defende-se que tais perfis possibilitam a autogestão e a organização do paciente quanto à alimentação adequada, práticas de atividades físicas, indicadores biológicos, índices glicêmicos e riscos comportamentais. A composição dos perfis decorre de informações sobre as condições crônicas do paciente, tais como: pressão, glicemia, cintura (ICQ), peso, entre outros, além de aspectos comportamentais, como a ingestão de medicamentos, atividades físicas, etc. O estudo visa criar um módulo para gerenciamento de perfis dinâmicos, voltado para cuidados com as DCNTs. Salienta-se que para a elaboração desta dissertação, elencam-se dois casos de pacientes portadores de doença aguda coronariana (DAC), que a principal causa de óbitos nas sociedades modernas. A revisão de literatura compreende investigações acerca do u-Health (CACERES et al., 2006), de perfis e de fatores de risco de doenças crônicas não transmissíveis. A realização do estudo contou com a parceria do PPG em Saúde Coletiva, da Unisinos, para a coleta de dados junto à pacientes em acompanhamento, por meio da aplicação criada no andamento desta pesquisa. A pesquisa é aplicada e centrada na proposição do módulo ChronicProfile, integrado ao modelo U’Ductor (VIANNA; BARBOSA, 2014). A implementação do protótipo envolve os seguintes componentes: 1) aplicação web ‘MeuCuidador Plano de Cuidado’, utilizada pelos médicos para cadastro do plano de cuidados; 2) aplicativo Android ‘MeuCuidador’, destinado aos pacientes para cadastro de informações acerca de suas atividades diárias. Os módulos do aplicativo compreendem a seleção e o processamento de históricos de contextos, a inferência e a geração de perfis, além das bases de dados específicas. Para avaliar a viabilidade do módulo proposto, dois tipos de experimentos foram desenvolvidos. O primeiro, vale-se de contextos reais de pacientes portadores de alguma DAC e trata da verificação de diferenças entre os perfis e da melhora das condições crônicas do paciente. Já no segundo experimento, avalia-se a capacidade do protótipo para geração de um perfil dinâmico para um mesmo paciente, mediante a inserção de um novo fator de risco a ser monitorado. Entre os resultados, destaca-se que a avaliação dos dados históricos de contextos e dos planos de cuidados de especialistas, realizada a partir do ChronicProfile, permite o monitoramento e a aferição do estado atual do paciente, a evolução ou involução dos fatores de risco relacionados a sua DCNT. / The contemporary scenario of noncommunicable chronic diseases (NCDs) is challenging. According to the latest report of the World Health Organization (WHO), in the global context, 38 million of deaths are a consequence of such diseases. For 2030, the number is expected to increase 52 million. Besides, the internet access and the proliferation of mobile devices, such as smartphones, are tools that facilitate the control and autonomous follow-up of patients. Furthermore, context-aware systems refer to transparent solutions for collecting users data that allow the identification of daily habits of individuals, which can be decisive in the treatment of diseases. The dynamic profile is a creation and automatic maintenance based on information and user Activities conforms the time cite Valmorbida2014. Therefore from detected contexts, profiles are defined, and the conversion between the two provides recommendations of personalized features to the patient. Considering this set of information, the research question is defined : how a model based on of Ubiquitous Computing could be designed to manage dynamic profiles in the monitoring of patients with NCDs? The study argue that those profiles supports the diseases control, allow the self-management and the organization of the patient specially about his proper nutrition, physical activities, biological indicators, glycaemic indices and behavioral risks. The profiles composition derives from information about the patient’s chronic conditions, such as: pressure, blood glucose, waist (WHR), weight, among others, besides the behavioral aspects, as medication intake, physical activities, etc. The study aims to create a module for dynamic profile management, focused on the attention to NCDs. The conduction of this research considers two cases from bearers patients of acute coronary disease (ACD), the main cause of death in modern societies. The literature review covers investigations about u-Health solutions (CACERES et al., 2006), of profiles and risk factors for noncommunicable chronic diseases. This applied research is centered in the proposition of a model called ChronicProfile, integrated to U’Ductor model (VIANNA; BARBOSA, 2014). The study was carried out with the partnership of PPG in Collective Health, from Unisinos, to collect data from the patients in follow-up, through the application created in the course of this research. The prototype implementation involves the follow components : 1) the web application « Meu Cuidador Plano de Cuidado », dedicated to medical utilization to register the care plan ; 2) the Android application « MeuCuidador », designed to patients to register informations about their daily activities. The application modules implies historic contexts selection and processing, the inference and generation of profiles, besides the specific data bases. The modules viability evaluation derives from two experimentals. First, real contexts from patients with some ACD were analysed to verify differences between profiles and the improvement of their chronic conditions. Secondly, the prototype capacity was evaluated to the generation of a dynamic profile to a same patient by inserting a new risk factor to be monitored. Among the results, the main one implies ChronicProfile’s data evaluation from historical contexts and care plans from specialists that permits monitoring and measurement of patient curent conditions, and also the NCDs risk factos of evolution or involution.

Submitted by Maicon Juliano Schmidt (maicons) on 2015-07-20T14:00:58Z No. of bitstreams: 1 Cassius Ariovaldo Paim_.pdf: 4051434 bytes, checksum: dc710d4c2c1f5860ca9842506743254f (MD5) / Made available in DSpace on 2015-07-20T14:00:58Z (GMT). No. of bitstreams: 1 Cassius Ariovaldo Paim_.pdf: 4051434 bytes, checksum: dc710d4c2c1f5860ca9842506743254f (MD5) Previous issue date: 2015-03-31 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Segundo a Organização Mundial da Saúde (OMS) em 2008 morreram em torno de 36 milhões de pessoas devido a doenças crônicas não transmissíveis (DCNTs) em todo o mundo. Para estes tipos de doenças é necessário o tratamento seja permanente e contínuo, ao encontro disto existem modelos para cuidado ubíquo de doenças crônicas não transmissíveis que suprem estas necessidades. Entretanto não se encontrou nenhum modelo genérico quanto ao tratamento de diferentes DCNTs, que vise incentivar o uso de recursos sensíveis ao contexto através da promoção de alteração no comportamento do usuário. Frente a isto, existem ferramentas como gamification, que se caracteriza pelo uso de elementos de jogos em contextos que não são jogos, esta ferramenta promove a alteração no comportamento incentivando o usuário através do uso recompensas. Considerando este conceito foi desenvolvido o modelo Octopus, um modelo de gamification para auxílio no cuidado ubíquo de DCNTs, que explora o uso dos recursos sensíveis ao contexto que auxiliem no cuidado ubíquo de DCNTs. Diferentemente de outros trabalhos, este modelo é genérico quanto ao tratamento de DCNTs, atende qualquer público, utiliza sensibilidade ao contexto e trilhas de recursos. Um protótipo do modelo foi avaliado através do uso de cenários. Através dessa avaliação foi possível verificar a viabilidade do modelo e o suporte a diversas DCNTs comprovando o aspecto genérico do modelo. / According to the World Health Organization (WHO) in 2008 died around 36 million people due to chronic non-communicable diseases (NCDs) worldwide. For these type of diseases is needed a permanent and continuous treatment, to against this there are models for ubiquitous care of noncommunicable diseases that meet these needs. However it was not found any generic model regarding the treatment of different NCDs, aimed at encouraging the use of context sensitive resources to promote the change of user behavior. Facing this, there are tools like gamification, which is characterized by the use of game elements in contexts that are not games, this tool promotes the change in behavior by encouraging the user through the use rewards. Considering this concept was developed Octopus model, a gamification model to aid in the ubiquitous care of NCDs, which explores the use of context sensitive resources that help the ubiquitous care of NCDs. Unlike other studies, this model is generic as to the treatment of NCDs, supports any public, uses context awareness and resources trails. A prototype of the model was evaluated through the use of scenarios, based on this evaluation was possible to verify the model’s viability and the support for several NCDs proving the generic aspect of the model.

<p>The aim of this thesis was to examine different approaches to support the self-care of persons with Type 2 diabetes, with special reference to practical, social, and sexual aspects of women's self-management. The methods to elucidate this comprised: evaluating a new model for diabetes patient education; designing a model to analyse the role of social networks in women's diabetes; conducting individual and focus group interviews for deeper understanding of the social and sexual aspects of diabetes; and collecting questionnaire data as a complement to the above.</p><p>The experience-based educational program led by pharmacists was found to improve participants' subjective control over diabetes and to provide important emotional support and encouragement to continue self-care. Metabolic control as measured by HbA_1c temporarily improved. The social network model elucidated potential mechanism leading to conflict of disease and social demands in women's diabetes. Qualitative analysis of the focus group interviews pointed to the role of guilt, shame, and social taboo in connection with the women's diabetes and sexuality.</p><p>Borderland is the metaphor I have chosen to describe the space between the traditional health care system and the everyday self-care of people with chronic disease. Using Borderland as a framework, a future model for diabetes management, anchored in our own and other's findings, is outlined and the concept of "Disease Manager Role" is introduced. The vision of a self-care support center in Borderland addresses such issues as accessibility, continuity, equitable provider-user relations, shared care plans, and strengthening social support.</p>