Electronic Patient Records (EPRs) are becoming standard tools in healthcare, lauded for improving patient access and outcomes. However, the healthcare professionals who work with, around, and despite these technologies in their daily practices often regard EPRs as troublesome. In order to investigate how EPRs can prompt such opposing opinions, this project examines the EPR as a collection of communication genres set in complex contexts. In this project, I investigate an EPR as it was used on the Nephrology ward at a large, Canadian, urban, paediatric teaching hospital. In this setting, this study investigates EPR-use in relation to the following aspects of context: (a) the visual rhetoric of the EPR's user-interface design; (b) the varied social contexts in which the EPR was used, including a diversity of professional collaborators who had varying levels of professional experience; (c) the span of social actions involved in EPR use; and (d) the other genres used in coordination with the EPR. <br /><br /> This qualitative study was conducted in two simultaneous stages, over the course of 8 months. Stage one consisted of a visual rhetorical analysis of a set of genres (including the EPR) employed by participants during a specific work activity. Stage two involved an elaborated, qualitative case study consisting of non-participant observations and semi-structured interviews. Stage two used a constructivist grounded theory methodology. A combination of theoretical perspectives -- Visual Rhetoric, Rhetorical Genre Studies, Activity Theory, and Actor-Network Theory -- supported the analysis of study data. This research reveals that participants routinely transformed EPR-based information into paper documents when the EPR's visual designs did not support the professional goals and activities of the participants. <br /><br /> Results indicate that healthcare professionals work around EPR-based patient information when that genre's visual organization is incompatible with professional activities. This study suggests that visual rhetorical analysis, complemented with observation and interview data, can provide useful insights into a genre's social actions. This research also examines the effects of such EPR-to-paper genre transformations. Although at one level of analysis, the EPR-to-paper-genre transformation may be considered inefficient for participants and so should be automated, at another level of analysis, the same transformation activity can be seen as beneficially supporting the detailed reviewing of patient information by healthcare professionals. <br /><br /> To account for this function in the transformation dysfunction, my research suggests that many contextual factors need to be considered during data analysis in order to construct a sufficiently nuanced understanding of a genre's social actions. To accomplish such an analysis, I develop a five-step approach to data analysis called 'context mapping. ' Context mapping examines genres in relation to the varied social contexts in which they are used, the span of social actions in which they are involved, and a range of genres with which they are coordinated. To conduct this analysis, context mapping relies heavily on theories of "genre ecologies" (Spinuzzi, 2003a, 2003b; Spinuzzi, Hart-Davidson & Zachry, 2004; Spinuzzi & Zachry, 2000) and "Knotworking" (Engestrom, Engestrom & Vahaaho, 1999). Context mapping's first three steps compile study data into results that accommodate a wide range of contextual analysis considerations. These three steps involve the use of a composite scenario of observation data, genre ecologies and the description of a starting point for analysis. The final two steps of this approach analyse results using the theory of Knotworking and investigate some of the implications of the patterns of genre use on the ward. <br /><br /> Through context mapping analysis, this study demonstrates that EPR-based innovations created by a study participant could result in the generation of other improvisations, in a range of genres, by the original participant and/or by other collaborators. These genre modifications had ramifications across multiple social contexts and involved a wide range of genres and associated social actions. Context mapping analysis demonstrates how the effects of participant-made EPR-based variations can be considered as having both beneficial and detrimental effects in the research site depending on the social perspective adopted. Contributions from this work are directed towards the fields of Rhetorical Genre Studies, Activity Theory research, and Health Informatics research, as well as to the research site itself. This study demonstrates that context mapping can support text-in-context style research in complex settings as a means for evaluating the effects of genre uses.

Electronic Patient Records (EPRs) are becoming standard tools in healthcare, lauded for improving patient access and outcomes. However, the healthcare professionals who work with, around, and despite these technologies in their daily practices often regard EPRs as troublesome. In order to investigate how EPRs can prompt such opposing opinions, this project examines the EPR as a collection of communication genres set in complex contexts. In this project, I investigate an EPR as it was used on the Nephrology ward at a large, Canadian, urban, paediatric teaching hospital. In this setting, this study investigates EPR-use in relation to the following aspects of context: (a) the visual rhetoric of the EPR's user-interface design; (b) the varied social contexts in which the EPR was used, including a diversity of professional collaborators who had varying levels of professional experience; (c) the span of social actions involved in EPR use; and (d) the other genres used in coordination with the EPR. <br /><br /> This qualitative study was conducted in two simultaneous stages, over the course of 8 months. Stage one consisted of a visual rhetorical analysis of a set of genres (including the EPR) employed by participants during a specific work activity. Stage two involved an elaborated, qualitative case study consisting of non-participant observations and semi-structured interviews. Stage two used a constructivist grounded theory methodology. A combination of theoretical perspectives -- Visual Rhetoric, Rhetorical Genre Studies, Activity Theory, and Actor-Network Theory -- supported the analysis of study data. This research reveals that participants routinely transformed EPR-based information into paper documents when the EPR's visual designs did not support the professional goals and activities of the participants. <br /><br /> Results indicate that healthcare professionals work around EPR-based patient information when that genre's visual organization is incompatible with professional activities. This study suggests that visual rhetorical analysis, complemented with observation and interview data, can provide useful insights into a genre's social actions. This research also examines the effects of such EPR-to-paper genre transformations. Although at one level of analysis, the EPR-to-paper-genre transformation may be considered inefficient for participants and so should be automated, at another level of analysis, the same transformation activity can be seen as beneficially supporting the detailed reviewing of patient information by healthcare professionals. <br /><br /> To account for this function in the transformation dysfunction, my research suggests that many contextual factors need to be considered during data analysis in order to construct a sufficiently nuanced understanding of a genre's social actions. To accomplish such an analysis, I develop a five-step approach to data analysis called 'context mapping. ' Context mapping examines genres in relation to the varied social contexts in which they are used, the span of social actions in which they are involved, and a range of genres with which they are coordinated. To conduct this analysis, context mapping relies heavily on theories of "genre ecologies" (Spinuzzi, 2003a, 2003b; Spinuzzi, Hart-Davidson & Zachry, 2004; Spinuzzi & Zachry, 2000) and "Knotworking" (Engestrom, Engestrom & Vahaaho, 1999). Context mapping's first three steps compile study data into results that accommodate a wide range of contextual analysis considerations. These three steps involve the use of a composite scenario of observation data, genre ecologies and the description of a starting point for analysis. The final two steps of this approach analyse results using the theory of Knotworking and investigate some of the implications of the patterns of genre use on the ward. <br /><br /> Through context mapping analysis, this study demonstrates that EPR-based innovations created by a study participant could result in the generation of other improvisations, in a range of genres, by the original participant and/or by other collaborators. These genre modifications had ramifications across multiple social contexts and involved a wide range of genres and associated social actions. Context mapping analysis demonstrates how the effects of participant-made EPR-based variations can be considered as having both beneficial and detrimental effects in the research site depending on the social perspective adopted. Contributions from this work are directed towards the fields of Rhetorical Genre Studies, Activity Theory research, and Health Informatics research, as well as to the research site itself. This study demonstrates that context mapping can support text-in-context style research in complex settings as a means for evaluating the effects of genre uses.

Despite rapid advances in technology, there is currently a complex, and somewhat disjointed approach to the way health information is collected, stored, and organized for both healthcare consumers and professionals. Incompatible electronic medical records from various healthcare providers add to the complexity of a system tasked with delivering a patient’s relevant medical information in a timely manner to the appropriate point of care. Personal health records (PHR) grew out of the efforts to produce an integrated electronic record to manage the multifaceted aspects of healthcare required by both healthcare consumers and professionals. PHRs are a transformative technology with the potential to alter patient-provider relationships in a way that produces a more efficient and cost effective healthcare system as a result of better patient outcomes. PHRs can potentially include a wide variety of users ranging from the lay public to clinical professionals. As such, it is important to identify potential user groups and their corresponding health information needs in order to design PHRs that maximize accessibility, usability, and clinical relevance. This study focused on laypeople who represented a wide age-range of individuals, evenly split in gender, with an above average level of computer literacy. Most of the participants had not used an electronic PHR prior to this study. However, after a hands-on session with PHR software, most participants found it to be easy to use, accompanied with the functionality they expected from such a system. Most participants were satisfied that an electronic PHR would meet their health information needs and would recommend the use of PHRs to family and friends. Anyone in the general public is a potential PHR user. However, this study found that individuals with chronic conditions and those with complex health needs had the most to gain from using a PHR as an integral part of their healthcare routine. This study also demonstrated that an individual’s health condition has a stronger influence on their perceptions about the usefulness of PHRs than does their demographic background (age, education, computer literacy). Finally, this study established that PHRs are considered by participants of the study to be useful tools in meeting their health information needs. / Graduate / 0723 / 0769 / 0984 / dguarin@uvic.ca

This study is a qualitative research on the faciliating and impeding factors that influence Hong Kong citizen's adoption of Electronic Health Record Sharing System (eHRSS), the principal electronic health record (EHR) system in Hong Kong.  A majority of the previous studies of EHR among information systems (IS) literature either focused within the institutional or technological perspectives, or on the perspectives of healthcare institutions or healthcare professionals. Little research has been done from citizens' perspective on factors of their adoption of EHR. There is also little research specific to Hong Kong's circumstances. This research aims to provide an enhanced understanding on the factors that influence citizens' EHR adoption through looking into eHRSS adoption in Hong Kong. It aims to provide contributions to bridge the knowledge gaps by providing a better understanding on adoption factors from citizens' perspective, and investigate into whether there are any unique factors applicable to Hong Kong. In this study, semi-structured interviews had been performed on participants covering various age groups to collect their views and opinions concering their adoption of eHRSS. With reference to theoretical constructs on user acceptance and adoption, this study identifies four facilitating factors for citizens' adoption of eHRSS, namely (i) knowledge, (ii) trust, (iii) perceived potential health benefits and (iv) flexibility and "stickiness" of continual use. Four impeding factors for citizens' non-adoption were also identified, namely (i) difficulty in registration, low level/lack of trust in EHR implementation, (iii) negativity on acceptance of new technology and (iv) perceived difficulty in usage.  In the concluding remarks, way forward for future research has been outlined. Practical recommendations have also been formulated for reference by relevant authorities in administering eHRSS in Hong Kong.

Since the 1990 the use of Electronic Patient Records (EPR) in health services has become increasingly prevalent world wide. EPR has become an important aspect of the continuous improvement of patient care. Transferring all patient records from paper based to electronic is now a priority for many health services. The research reported in this thesis is sponsored by Hamad Medical Corporation (HMC) to provide opportunity to explore the potential role for EPR in the Medical Records Department. The study has been designed to gain better understanding of the users perspectives with regard to the use of patient records. In order to analyse and understand the complex dynamic involved in the management and use of patient records, it was recognised that systems thinking offered an appropriate framework for this research. Soft System Methodology (SSM) was therefore applied to the analysis of the data and used to inform the development of a conceptual model. Using SSM in combination with the structured questionnaire survey and telephone semi-structured interview, triangulation of methods was achieved. Use of these generated rich data revealing for example the general dissatisfaction expressed with the existing manual patient records system, the lack of confidentiality, poor legibility, shortage of space and the frequent misfiling of records. The need to address these problems has informed the strategic plan for the development and implementation of EPR for HMC. The research has successfully addressed the stated aims and research questions and guided the formulation of proposals for improvements.

<p>Den dokumentation som görs i patientjournaler får allt större betydelse för patientens säkerhet och delaktighet samt för uppföljning och utveckling av vårdens kvalitet. IT-stöd ökar informationens tillgänglighet, men studier visar på brister vad gäller struktur och innehåll.</p><p>Syftet med denna studie var att kartlägga i vilken omfattning dubbeldokumentation förekom i den tvärprofessionella, elektroniska patientjournalen, relaterat till sjuksköterskans dokumentation (delstudie I), samt att undersöka personals uppfattningar om dubbeldokumentation och värdet av att använda egen och annan professions dokumentation (delstudie II).</p><p>Studien genomfördes på ett länsdelssjukhus där datorjournaler använts i ca 10 år. Trettio strokepatienters journaler analyserades utifrån VIPS-modellens sökord och arbetsterapeuter, läkare, sjukgymnaster och sjuksköterskor (N = 111) besvarade en studiespecifik enkät.</p><p>Resultatet visade att 15 % av innehållet i omvårdnadsdokumentationen (exklusive epikris) också fanns dokumenterat på annan plats i journalen, en eller flera gånger. Av omvårdnadsanamnesernas innehåll var 43 % dubbeldokumenterat. Motsvarande andel för omvårdnadsstatus och omvårdnadsåtgärder var 6 % respektive 10 %. När det gäller omvårdnadsepikriserna var 41 % av innehållet även dokumenterat i annan professions epikris. Dubbeldokumentationer förekom oftare mellan sjuksköterska och läkare än mellan sjuksköterska och arbetsterapeut/sjukgymnast. Samtliga professioner ansåg det värdefullt att kunna ta del av varandras dokumentation. Läkarens dokumentation följdes i stor utsträckning av alla. Arbetsterapeuter, sjukgymnaster och sjuksköterskor följde varandras dokumentation i stor utsträckning. Det var vanligare att man sökte specifik information än läste dokumentationen för att skaffa sig en helhetsbild. Sjuksköterskor sökte också ofta information för att i sin tur lämna denna vidare. Dubbeldokumentation ansågs förekomma mest inom journalens anamnesdel. Tänkbara orsaker till dubbeldokumentation ansågs vara att man inte läser vad andra har dokumenterat, att man vill visa vad som gjorts samt att diktaten skrivs in för sent. Vid jämförelse mellan sjuksköterskor med äldre utbildning respektive de med utbildning enligt 1993 års studieordning visades att sjuksköterskor med äldre utbildning instämde i högre utsträckning till att dubbeldokumentation ofta förekommer mellan läkare och sjuksköterska.</p><p>För att undvika onödig dubbeldokumentation krävs, förutom att aktuell information finns tillgänglig, att roller och ansvarsförhållanden mellan professionerna tydliggjorts.</p> / <p>The documentation made in patients’ charts is becoming of greater importance for the safety and involvement of patients and for the follow up and development of the quality of care. IT support increases the accessibility of information, but studies even show deficits pertaining to structure and content. The aim for this study was to survey to what extent double documentation occurs in multiprofessional, electronic patient charts, related to the nurse’s documentation and to investigate staffs’ understanding of the value and usage of other professionals’ documentation.</p><p>The study was conducted at a county hospital where computer charts have been in use for about 10 years. Thirty stroke patients’ charts were analysed on the basis of the VIPS models key words and occupational therapists, physicians, physiotherapists, and nurses completed a study specific survey.</p><p>The results showed that 15% of the content in nursing care documentation (excluding epicrisis) was also documented in other places in the chart, one or more times. Of the content of the nursing anamnesis 43% were double documented. The corresponding share of the nursing status and nursing interventions were 6% respectively 10%. When it comes to nursing epicrisis 41% of the content was also documented in other professionals’ epicrisis. Double documentation occurs more often between nurses and physicians than between nurses and occupational therapists/physiotherapists.</p><p>All of the occupations considered that it is valuable to be able to take part in each others documentation. Physicians’ documentation was followed to a great extent by all. Occupational therapists, physiotherapists, and nurses followed each others documentation to a great extent. It was more common to seek specific information that to read the documentation in order to acquire an overall picture. Nurses sought also often information which in turn was given to others. Double documentation was considered to occur mostly in the section of the chart for anamnesis. Conceivable reasons for double documentation were considered to be caused by not reading what others had documented, to show what had been done, and that dictation was written in too late. At a comparison between nurses with an older education and those with an education according to the 1993 curriculum showed that nurses with an older education agreed to a greater extent that double documentation occurred between physicians and nurses.</p><p>Avoiding unnecessary double documentation demands, besides that current information is available, that the conditions of rolls and responsibilities between professionals are clarified.</p>

Background and aims: Most respiratory tract infections (RTI) are self-limiting. Despite this, they are associated with high antibiotic prescription rates in general practice in Sweden. The aim of this thesis was to evaluate the management of respiratory tract infections (RTIs) with particular emphasis on acute otitis media (AOM). Methods: Paper I: A prospective, open, randomized study of 179 children presenting with AOM and performed in primary care. Paper II &amp; III: Study of 6 years data from primary care in Kalmar County on visits for RTI, retrieved from electronic patient records. Paper IV: Observational, clinical study of 71 children presenting with AOM complicated by perforation, without initial use of antibiotics. Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II &amp; III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by &gt;10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP&lt;50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics. Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II &amp; III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by &gt;10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP&lt;50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics.

Den dokumentation som görs i patientjournaler får allt större betydelse för patientens säkerhet och delaktighet samt för uppföljning och utveckling av vårdens kvalitet. IT-stöd ökar informationens tillgänglighet, men studier visar på brister vad gäller struktur och innehåll. Syftet med denna studie var att kartlägga i vilken omfattning dubbeldokumentation förekom i den tvärprofessionella, elektroniska patientjournalen, relaterat till sjuksköterskans dokumentation (delstudie I), samt att undersöka personals uppfattningar om dubbeldokumentation och värdet av att använda egen och annan professions dokumentation (delstudie II). Studien genomfördes på ett länsdelssjukhus där datorjournaler använts i ca 10 år. Trettio strokepatienters journaler analyserades utifrån VIPS-modellens sökord och arbetsterapeuter, läkare, sjukgymnaster och sjuksköterskor (N = 111) besvarade en studiespecifik enkät. Resultatet visade att 15 % av innehållet i omvårdnadsdokumentationen (exklusive epikris) också fanns dokumenterat på annan plats i journalen, en eller flera gånger. Av omvårdnadsanamnesernas innehåll var 43 % dubbeldokumenterat. Motsvarande andel för omvårdnadsstatus och omvårdnadsåtgärder var 6 % respektive 10 %. När det gäller omvårdnadsepikriserna var 41 % av innehållet även dokumenterat i annan professions epikris. Dubbeldokumentationer förekom oftare mellan sjuksköterska och läkare än mellan sjuksköterska och arbetsterapeut/sjukgymnast. Samtliga professioner ansåg det värdefullt att kunna ta del av varandras dokumentation. Läkarens dokumentation följdes i stor utsträckning av alla. Arbetsterapeuter, sjukgymnaster och sjuksköterskor följde varandras dokumentation i stor utsträckning. Det var vanligare att man sökte specifik information än läste dokumentationen för att skaffa sig en helhetsbild. Sjuksköterskor sökte också ofta information för att i sin tur lämna denna vidare. Dubbeldokumentation ansågs förekomma mest inom journalens anamnesdel. Tänkbara orsaker till dubbeldokumentation ansågs vara att man inte läser vad andra har dokumenterat, att man vill visa vad som gjorts samt att diktaten skrivs in för sent. Vid jämförelse mellan sjuksköterskor med äldre utbildning respektive de med utbildning enligt 1993 års studieordning visades att sjuksköterskor med äldre utbildning instämde i högre utsträckning till att dubbeldokumentation ofta förekommer mellan läkare och sjuksköterska. För att undvika onödig dubbeldokumentation krävs, förutom att aktuell information finns tillgänglig, att roller och ansvarsförhållanden mellan professionerna tydliggjorts. / The documentation made in patients’ charts is becoming of greater importance for the safety and involvement of patients and for the follow up and development of the quality of care. IT support increases the accessibility of information, but studies even show deficits pertaining to structure and content. The aim for this study was to survey to what extent double documentation occurs in multiprofessional, electronic patient charts, related to the nurse’s documentation and to investigate staffs’ understanding of the value and usage of other professionals’ documentation. The study was conducted at a county hospital where computer charts have been in use for about 10 years. Thirty stroke patients’ charts were analysed on the basis of the VIPS models key words and occupational therapists, physicians, physiotherapists, and nurses completed a study specific survey. The results showed that 15% of the content in nursing care documentation (excluding epicrisis) was also documented in other places in the chart, one or more times. Of the content of the nursing anamnesis 43% were double documented. The corresponding share of the nursing status and nursing interventions were 6% respectively 10%. When it comes to nursing epicrisis 41% of the content was also documented in other professionals’ epicrisis. Double documentation occurs more often between nurses and physicians than between nurses and occupational therapists/physiotherapists. All of the occupations considered that it is valuable to be able to take part in each others documentation. Physicians’ documentation was followed to a great extent by all. Occupational therapists, physiotherapists, and nurses followed each others documentation to a great extent. It was more common to seek specific information that to read the documentation in order to acquire an overall picture. Nurses sought also often information which in turn was given to others. Double documentation was considered to occur mostly in the section of the chart for anamnesis. Conceivable reasons for double documentation were considered to be caused by not reading what others had documented, to show what had been done, and that dictation was written in too late. At a comparison between nurses with an older education and those with an education according to the 1993 curriculum showed that nurses with an older education agreed to a greater extent that double documentation occurred between physicians and nurses. Avoiding unnecessary double documentation demands, besides that current information is available, that the conditions of rolls and responsibilities between professionals are clarified.