Even though most clinical information systems (CIS) today are technically sound, the number of successful implementations of these systems is low. For that reason, understanding the characteristics and challenges for organizations implementing CIS is now considered key to successful information technology deployment (Lorenzi & Riley, 1997). Although theory driven information systems models and CIS studies exist, an integrated model to predict a successful CIS has not been evaluated. The purpose of this research was to evaluate the ability of a theoretically-based integrated model of CIS success (CISSM) to predict a successful CIS from the clinicians' perspective. Data were collected and analyzed from 234 registered nurses in 4 hospitals who had used the Cerner PowerChart Admission Health Profile (AHP) longer than 3 months. Construct validity and internal consistency reliability of the 23-item online instrument were established. The results of stepwise multiple regression analyses provided tentative support for the CISSM model.

We present Information System Hazard Analysis (ISHA), a novel systemic hazard analysis technique focused on Clinical Information System (CIS)s. The method is a synthesis of ideas from United States Department of Defense Standard Practice System Safety (MIL-STD-882E), System Theoretic Accidents Models and Processes (STAMP) and Functional Resonance Analysis Method (FRAM). The method was constructed to fill gaps in extant methods for hazard analysis and the specific needs of CIS. The requirements for the method were sourced from existing literature and from our experience in analysis of CIS related accidents and near misses, as well as prospective analysis of these systems. The method provides a series of iterative steps which are followed to complete the analysis. These steps include modelling phases that are based on a combination of STAMP and FRAM concepts. The method also prescribes the use of triangulation of hazard identification techniques which identify the effects of component and process failures, as well as failures of the System Under Investigation (SUI) to satisfy its safety requirements. Further to this new method, we also contribute a novel hazard analysis model for CIS as well as a safety factor taxonomy. These two artifacts can be used to support execution of the ISHA method. We verified the method composition against the identified requirements by inspection. We validated the method’s feasibility through a number of case studies. Our experience with the method, informed by extant safety literature, indicates that the method should be generalizable to information systems outside of the clinical domain with modification of the team selection phase. / Graduate

Critical care nurses work in an environment rich in informative interactions. Although there have been post hoc self-report survey studies of nurses' information seeking, there have been no observational studies of the patterns and content of their on-duty information behavior. This study used participant observation and in-context interviews to describe 50 hours of the observable information behavior of a representative sample of critical care nurses in a 20-bed critical care hospital unit. The researcher used open, in vivo, and axial coding to develop a grounded theory model of their consistent pattern of multimedia interactions. The resulting Nurse's Patient-Chart Cycle describes nurses' activities during the shift as centering on a regular alternation with the patient and the patient's chart (various record systems), clearly bounded with nursing "report" interactions at the beginning and the end of the shift. The nurses' demeanor markedly changed between interactions with the chart and interactions with the patient. Other informative interactions were observed with other health care workers and the patient's family, friends and visitors. The nurses' information seeking was centered on the patient. They mostly sought information from people, the patient record and other digital systems. They acted on or passed on most of the information they found. Some information they recorded for their personal use during the shift. The researcher observed the nurses using mostly patient specific information, but they also used some social and logistic information. They occasionally sought knowledge based information. Barriers to information acquisition included illegible handwriting, difficult navigation of online systems, equipment failure, unavailable people, social protocols and mistakes caused by multi-tasking people working with multiple complex systems. No formal use was observed of standardized nursing diagnoses, nursing interventions, or nursing outcomes taxonomies. While the nurses expressed respect for evidence-based practice, there clearly was no time or opportunity for reading research literature (either on paper or online) while on duty. All participants expressed frustration with the amount of redundant data entry required of them. The results of this study have significant implications for the design of clinical information systems and library services for working critical care nurses.

Ο ηλεκτρονικός ιατρικός φάκελος κάθε πολίτη της χώρας αποτελείται από ιατρικές πληροφορίες που παράγονται γι' αυτόν, σε οποιονδήποτε φορέα παροχής υπηρεσιών υγείας. Σε κάθε Κέντρο Υγείας εγκαθίσταται πλήρης υποδομή για την τήρηση και ενημέρωση στοιχείων του ηλεκτρονικού ιατρικού φακέλου και για την πρόσβαση σε στοιχεία τα οποία τηρούνται σε άλλους φορείς παροχής υπηρεσιών υγείας όλων των κατοίκων που υπάγονται σε αυτό. Ο οικογενειακός και ο προσωπικός ιατρός υποχρεούται να ενημερώνει τους ηλεκτρονικούς ιατρικούς φακέλους των ασφαλισμένων που τον έχουν επιλέξει με τις πληροφορίες οι οποίες παράγονται από τον ίδιο. Ο πολίτης – ασθενής θα πρέπει να έχει και τη δυνατότητα να λαμβάνει σε ηλεκτρονική μορφή έναν προσωπικό ιατρικό φάκελο ο οποίος θα τον διευκολύνει στην πρόσβασή του στις υπηρεσίες υγείας της χώρας και στην άμεση εξασφάλιση παροχής αναγκαίων πληροφοριών και δεδομένων σχετικών με την υγεία του. Ο προσωπικός ηλεκτρονικός ιατρικός φάκελος μπορεί να περιέχει και άλλες προσωπικές πληροφορίες που αποτυπώνουν αναλυτικά την πιο πρόσφατη κατάσταση του ασθενούς (π.χ. μετά από έκτακτη εισαγωγή ή επίσκεψη σε ιατρό), οι οποίες θα μπορούν να τροποποιηθούν και από τον ίδιο. Η διπλωματική εργασία έχει ως στόχο την ανάπτυξη ενός τέτοιου προσωπικού ηλεκτρονικού ιατρικού φακέλου με την αξιοποίηση τεχνολογιών βάσεων δεδομένων και Διαδικτύου. / The electronic medical file of each citizen of country is constituted by medical information that is produced for him, in any institution of benefit of services of health. In each Centre of Health is installed complete infrastructure for the observation and briefing of elements of electronic medical file and for the access in elements which are observed in other institutions of benefit of services of health of all residents that be governed in this. The familial and personal doctor is compelled to inform the electronic medical files secured that have selected him with the information that is produced by the himself. The citizen - patient will be supposed has also the possibility receives in electronic form a personal medical file which will facilitate him in his access in the services of health of country and in the direct guarantee of benefit of necessary information and given relative with his health.The personal electronic medical file can contain also other personal information that impresses analytically the most recent situation of patient (eg after extraordinary import or visit in doctor), that might be also modified from himself. The diplomatic work aims at as the growth of such personal electronic medical file with the exploitation of technologies of bases of data and Internet.

INTRODUCTION: While mobile device use by physicians increases, there is an increased risk that errors committed while using mobile devices can lead to harm. This mixed-method study evaluates the effects of screen size on clinical users’ perceptions of medical application usability and safety when interfacing to critical patient information. In this research, two mobile devices are examined: iPhone® and the iPad®. METHOD: Eleven physicians and one nurse practitioner participated in a chart-review simulation using an app that was an end-point to an electronic health record. Screen-recording, video-recording and a think-aloud protocol were used to gather data during the simulation. Additionally, participants completed Likert-based questionnaires and engaged in semi-structured interviews. RESULTS: A total of 105 usability, usefulness and safety problems were recorded and analysed. A strong preference was found for the larger screen when reviewing patient data due to the large quantity of data and the increased display size. The smaller device was preferred due to the devices portability when participants needed to remain informed when they were away from the point of care. CONCLUSION: There is an association between screen size and the perceived safety of the handheld device. The iPad was perceived to be safer to use in clinical practice. Participants preferred the iPad® because of the larger size, not because they thought it was safer or easier to use. The iPhone® was preferred for its portability and its usefulness was perceived to increase with greater distance from the point of care. / Graduate

Cette thèse, rédigée par articles, vise à examiner d’un point de vue pratique et théorique les enjeux sous-jacents à la capacité des infirmières d’agir sur leur pratique et son contexte par l’entremise d’interventions d’audit-feedback. L’audit-feedback est couramment utilisé dans le domaine de la santé en soutien aux changements et à l’amélioration des pratiques professionnelles. Bien que les infirmières soient régulièrement impliquées dans ces interventions, celles-ci sont étudiées surtout auprès des médecins, tant d’un point de vue empirique que théorique. Le contexte de pratique des infirmières comporte des caractéristiques peu facilitatrices à l’efficacité de l’audit-feedback. La méthodologie de développement théorique d’Alvesson et Kärreman (2007, 2011) a été utilisée afin de comprendre comment ces interventions pouvaient permettre aux infirmières d’agir sur leur pratique et son contexte. Le premier volet de la thèse implique une analyse de deux sources de données empiriques. D’abord, une revue systématique mixte a été effectuée pour comprendre les effets mesurés et perçus de l’audit-feedback auprès des infirmières. Les données des 13 études quantitatives suggèrent une efficacité très variable de l'audit-feedback. Les caractéristiques de la plupart des interventions étaient peu conformes aux recommandations actuelles dans le domaine. Globalement, les données des 18 études qualitatives suggèrent que les infirmières perçoivent plusieurs aspects négatifs à l’audit-feedback, tout en reconnaissant la pertinence d’une utilisation secondaire des données pour soutenir l'amélioration des soins. La seconde source de données provient d’une étude pilote sur le développement, la mise à l’essai et l’évaluation d’une intervention d’audit-feedback auprès d’une équipe de soins infirmiers en première ligne. Des indicateurs relatifs aux soins de plaies et mesurés à partir du système d’information I-CLSC ont été rapportés à l’équipe lors de deux séances de rétroaction. Des analyses de régression logistique ont été effectuées sur une période de 24 mois à partir de 1605 épisodes de soins de plaies afin d’évaluer l’évolution des indicateurs avant, pendant et après la période d’intervention. Un seul indicateur, celui de soutien à l’auto-gestion, a démontré une amélioration constante. L’analyse de ces données empiriques en fonction d’un cadre théorique spécifique à l’audit-feedback (Brown et al., 2019) a permis dans le second volet de la thèse de formuler trois hypothèses sur la réponse des infirmières à l’audit-feedback. Les hypothèses impliquent 1) une intégration de l’aspect relationnel de la pratique infirmière à la rétroaction; 2) une priorisation de la mesure d’indicateurs auprès de l’équipe proximale et 3) une prise en compte des intérêts de l’audit-feedback pour la pratique des infirmières. La démarche se conclut par une réflexion théorique sur les enjeux sous-jacents à l’aspect collectif de l’action chez les infirmières et des intérêts pour leur pratique en levier aux changements. À partir de notions de la théorie de l’Agir communicationnel de Jürgen Habermas, la pratique infirmière est abordée sous l’angle de la coordination communicationnelle et fonctionnelle. Cette problématisation théorique permet, en discussion finale de la thèse, de définir les principales pistes d’action pour concevoir et mettre en œuvre des interventions d’audit-feedback qui répondent à la fois aux intérêts des infirmières et du système de santé. / This manuscript-style thesis aims to examine from a practical and theoretical perspective the issues underlying nurses' ability to act on their practice and its context through audit and feedback interventions. Audit and feedback is commonly used in the health care to support change and improvement in professional practice. Although nurses are regularly involved in these interventions, they are studied primarily with physicians, both empirically and theoretically. The practice context of nurses has characteristics that are not conducive to the effectiveness of audit and feedback. Alvesson and Kärreman's (2007, 2011) theory development methodology was used to understand how these interventions could enable nurses to act on their practice and its context. The first component of the thesis involves an analysis of two sources of empirical data. First, a mixed-methods systematic review was conducted to understand the measured and perceived effects of audit and feedback with nurses. The data from 13 quantitative studies suggest a highly variable effectiveness of audit and feedback. The characteristics of most of the interventions were poorly aligned with current recommendations. Overall, the data from the 18 qualitative studies suggest that nurses perceive several negative aspects to audit and feedback, while recognizing the relevance of secondary use of data to support the improvement of care. The second source of data comes from a pilot study on the design, testing, and evaluation of an audit and feedback intervention with a primary care nursing team. Wound care indicators measured from the I-CLSC information system were reported to the team in two feedback sessions. Logistic regression analyses were performed over a 24-month period on 1605 wound care episodes to assess changes in indicators before, during, and after the intervention period. Only one indicator, self-management support, showed consistent improvement. Analysis of this empirical data based on an audit and feedback specific theory (Brown et al., 2019) led to three hypotheses about nurses' response to audit and feedback in the second component of the thesis. The hypotheses involve 1) integrating the relational aspect of nursing into the feedback; 2) prioritizing the use of indicators targeting teams; and 3) considering the benefits of audit and feedback for nursing practice. The theory development approach concludes with a theoretical reflection on the issues underlying the collective aspect of action among nurses and the interests for their practice as a lever for change. Using notions from Jürgen Habermas' theory of communicative action, nursing practice is viewed from the perspective of communicative and functional coordination. This theoretical perspective allows, in the final discussion of the thesis, to define the main avenues for designing and implementing audit and feedback interventions that meet the interests of both nurses and the health care system.

Research in risk awareness has been relatively neglected in the health informatics literature, which tends largely to examine project managers’ perspectives of risk awareness; very few studies explicitly address the perspectives held by senior executives such as directors. Another limitation evident in the current risk literature is that studies are often based on American data and/or they are restricted to American culture. Both factors highlight the need to examine how senior executives (i.e., directors) who oversee or direct eHealth projects in Canada perceive risk awareness. This research explores and discusses the perspectives of risk awareness (i.e., identification, analysis, and prioritization) held by directors and project managers who implement Canadian eHealth projects. Semi-structured interviews with nine directors and project managers uncovered six key distinctions in these two groups’ awareness of risk. First, all project managers valued transparency over anonymity, whereas directors believed that an anonymous reporting system for communicating risks had merit. Secondly, most directors emphasized the importance of evidence-based planning and decision making when balancing risks and opportunities, an aspect none of the project managers voiced. Thirdly, while project managers noted that the level of risk tolerance may evolve from being risk-averse to risk-neutral, directors believed that risk tolerance evolved toward risk-seeking. Directors also noted the importance of employing risk officers, a view that was not shared by project managers. Directors also believed the risk of too little end-user engagement and change management was the most important risk, whereas project managers ranked it as the least important. Finally, when directors and project managers were asked to identify and define the root cause(s) of eHealth risks, directors identified the complexity of health care industry, while project managers attributed it to political pressure and a lack of resources where eHealth projects are concerned. This research proposes that the varied perspectives of risk awareness held by directors and project managers must be considered and integrated to properly align expectations and build partnerships for successful eHealth project outcomes. Understanding risk awareness offers a means to systematically identify and analyze the complex nature of eHealth projects by embracing uncertainties, thereby enabling forward thinking (i.e., staying one step ahead of risks) and the ability to prevent avoidable risks and seize opportunities. / Graduate / 0723 / 0489 / 0454 / randbpark@gmail.com