The author investigates the performance of a time series based approach in predicting the risk of patients abandoning treatment in a treatment program for childhood obesity. The time series based approach is compared and contrasted to an approach based on static features (which has been applied in similar problems). Four machine learning models are constructed; one ‘Main model’ using both time series forecasting and three ‘reference models’ created by removing or exchanging parts of the main model to test the performance of using only time series forecasting or only static features in the prediction. The main model achieves an ROC-AUC of 0.77 on the data set. ANOVA testing is used to determine whether the four models perform differently. A difference cannot be verified at the significance level of 0.05, and thus, the author concludes that the project cannot show either an advantage or a disadvantage to employing a time series based approach over static features in this problem. / Författaren jämför modeller baserade på tidsserieförutsägelser med modeller baserade på statiska, fasta värden, till syfte att identifera patienter som riskerar att lämna ett behandlingsprogram för barnfetma. Fyra maskininlärningsmodeller konstrueras, en ‘Huvudmodell’ som använder sig av både tidsserieförutsägelser och statiska värden, och tre modeller som bryter ut delar av huvudmodellen för undersöka beteendet i modeller baserade enbart på statiska värden respektive enbart baserade på tidsserieförutsägelser. Huvudmodellen uppnår ROC-AUC0.77 på datasetet. ANOVA(variansanalys) används för att avgöra huruvida de fyra modellernas resultat skiljer sig, och en skillnad kan ej verieras vid P = 0:05. Följaktligen drar författaren slutsatsen att projektet inte har kunnat visa vare sig en signifikant fördel eller nackdel med att använda sig av tidsserieförutsägelser inom den aktuella problemdomänen.

Shared electronic health record (EHR) systems constitute an important Telemedicine and e-Health application. Successful implementation of shared health records calls for a satisfactory level of security. This is invariably achieved through applying and enforcing strict, and often quite complicated, rules and procedures in the access process. For this reason, information security strategy for EHR systems is needed to be in place. This research reviewed the definition of different terms that related to electronically stored and shared health records and delineated related information security terms leading to a definition of an information security strategy. This research also made a contribution to understanding information security strategy as a significant need in EHR systems. A major case study of the National Programme for IT (NPfIT) in England is used to be the container of other two sub-case studies in two different Acute Trusts. Different research methods used: participant observation and networking, semi-structured interviews, and documentary analysis. This research aimed to provide a comprehensive understanding to the information security strategy of England’s EHR system by presenting its different information security issues such as consent mechanisms, access control, sharing level, and related legal and regulatory documents. Six factors that influence the building of an information security strategy in EHR systems, were identified in this research, political, social, financial, technical, clinical and legal. Those factors are considered to be driving the strategy directly or indirectly. EHR systems are technical-clinical systems, but having other factors (than technical and clinical) that drive this technical-clinical system is a big concern. This research makes a significant contribution by identifying these factors, and in addition, this research shows not only how these factors can influence building the information security strategy, but also how they can influence each other. The study of the mutual influence among the six factors led to the argument that the most powerful factor is the political factor, as it directly or indirectly influences the remaining five factors. Finally, this research proposes guidelines for building an information security strategy in EHR systems. These guidelines are presented and discussed in the form of a framework. This framework was designed after literature analysis and after completing the whole research journey. It provides a tool to help putting the strategy in line by minimising the influence of various factors that may steer the strategy to undesirable directions.

Objective: The researcher replicated 12 questions from a previous user satisfaction study for the C-HOBIC assessment tool at St. Boniface Hospital in Winnipeg Manitoba. The research questions were: (a) what is user satisfaction regarding the C-HOBIC assessment tool 20 months after implementation, (b) has user satisfaction changed since the first evaluation, and (c) do user demographics correlate with user satisfaction and the C-HOBIC assessment tool? Method: 20 months after the previous study (Canadian Nurses Association, 2015), a convenience sample of 71 participants from a pool of approximately 700 clinicians completed an online survey comprised of 12 questions taken from the previous study. Results: The data were analyzed using Shapiro-Wilk, descriptive statistics, chi-square test for independence, and Spearman’s correlation. The Likert-style survey produced discrete, ranked data that did not follow a normal distribution. Overall user satisfaction with the C-HOBIC assessment tool was rated higher in the previous group (n=59) as compared to user satisfaction in the current group (n=71). There was a significant but weak correlation with gender and C-HOBIC patient outcomes positively influencing patient care directions, and improving patient care planning. A significant but weak correlation existed between the years of a participant's clinical experience and the ease of integrating C-HOBIC into practice. Conclusions: There were more participants not satisfied with the use of the C-HOBIC assessment tool than were satisfied. Participants in this study had less user satisfaction with the C-HOBIC assessment tool and associated outcomes than participants from a similar study 20 months before. Gender and years of clinical experience are correlated with user satisfaction. The small sample size, the non-normally distributed data, and convenient sampling method do not support generalization of the results beyond the data set. / Graduate / 0569 / alshunt@gmail.com

Empiric antimicrobial therapy often consists of the combination of Gram-positive coverage with vancomycin (VAN) and Gram-negative coverage, specifically an anti-pseudomonal beta-lactam, such as piperacillin-tazobactam (PTZ). Nephrotoxicity is commonly associated with VAN therapy; however, recent reports demonstrate increasing nephrotoxicity rates among patients treated with the combination of VAN and PTZ. This study evaluated the effect of the VAN/PTZ combination on acute kidney injury (AKI), as defined by the RIFLE criteria, compared to VAN and PTZ monotherapies. Overall, 11,650 patients were analyzed, with 1,647 (14.1%) AKI cases occurring. AKI was significantly more frequent in the VAN/PTZ group (21%) compared to either monotherapy group (VAN 8.3%, PTZ 7.8%, p<0.001 for both). Combination therapy was independently associated with higher AKI odds compared to monotherapy with either agent (aOR=2.03; 95% CI 1.74-2.39; aOR=2.31; 95% CI 1.97-2.71, for VAN and PTZ, respectively). Receipt of concomitant nephrotoxic drugs were independently associated with increased AKI rates, as were increased duration of therapy, length of hospital stay, increasing severity of illness, and increasing baseline renal function. VAN combined with PTZ was associated with twice the odds of AKI development compared to either agent as monotherapy. This demonstrates the need for judicious use of combination empiric therapy.

Abstract PATTERNS IN CHAPLAIN DOCUMENTATION OF ASSESSMENTS AND INTERVENTIONS, A DESCRIPTIVE STUDY by Kevin Eugene Adams, MDiv A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University, 2015 Diane Dodd-McCue, D.B.A, Department of Patient Counseling There is increasing emphasis on the importance of evidence-based care provided by all disciplines in healthcare. The Electronic Health Record (EHR) is becoming the standard for communicating assessments, plans of care, interventions, and outcomes of patient care. The spiritual care literature demonstrates the importance of assessing religious/spiritual needs and resources and developing plans of care to address the results of such assessment (Anandarajah & Hight, 2001; Borneman, Ferrell, & Puchalski, 2010; Fitchett, 1999; Fitchett & Risk, 2009; H. G. Koenig, 2007). This literature also suggests that addressing religious/spiritual needs of patients and families in the healthcare context can affect healthcare and adherence outcomes. The purpose of this study was to identify patterns of chaplain assessment and patterns of chaplain provision of services. This descriptive study was an exploratory retrospective analysis of categorical data recorded by clinical staff chaplains in the EHR at a single all pediatric healthcare institution, using contingency tables and frequency tables. The study examined chaplain use of assessment and service descriptors and the patterns of these descriptors when documenting chaplain visits. The results indicate chaplain preference for communicating in the EHR using general themes and concepts. This reveals an opportunity for chaplains to develop and implement a model of professional identity and articulation of care that is broad enough to accommodate the diversity of religion/spirituality chaplains encounter, yet able to articulate the specifics of patient and family religion/spirituality. The results found no consistent patterns among assessments or services provided. Further, the results found no indication of patterns between assessments made and the services provided. This presents an opportunity for chaplains to develop and implement a theory-driven, construct-based model of care that will connect the different facets of spiritual care. The assessments made will lead to plans of care that involve specific interventions resulting in appropriate outcomes related to overall patient and family care.

Personal Health Records (PHRs) allow patients to access and in some cases manage their own health records. Their potential benefits include access to health information, enhanced asynchronous communication between patients and clinicians, and convenience of online appointment scheduling and prescription refills. Potential barriers to PHR use include lack of computer and internet access, poor computer or health literacy, security concerns, and provider disengagement. PHRs may help those living in rural areas and those with chronic conditions such as heart failure, monitor and manage their disease, communicate with their health care team and adhere to clinical recommendations. To provide some much needed actual research, a descriptive mixed methods study of the usability, usefulness, and disease management potential of PHRs for rural heart failure patients was conducted. Fifteen participants were enrolled. Usability issues fell into three categories: screen layout; applying consistent, standard formatting; and providing concise, clear instructions. Participants used PHR features that were more convenient than other methods or that had some additional benefit to them. There was no difference between rural and urban participants. A heart failure nurse promoted recording daily heart failure symptoms in the PHR. Most participants did so at least once, but many found it cumbersome. Reasons for recording included the comfort of having clinical staff monitor the data. Participants who were stable did not find recording as useful as did those who were newly diagnosed or unstable. Participants used asynchronous communication to send messages to the heart failure nurse that they would not otherwise have communicated. The study expands the knowledge of PHR use by addressing useful functionality and disease management tools among rural patients with heart failure. The patients were able to complete tasks they found useful. The increased communication and disease management tools were useful to some.

This master thesis contributes to a growing body of literature analysing electronic health records (EHRs) and their importance to potentially optimization of the work flow in small medical practices. Additionally, general information about different health care systems is given, especially about the Canadian health care system. It gives a theoretical overview of information technologies used through health care providers. This thesis addresses the new technologies for communication and describes them. Problem: The "lack of clear channels of communication in patient transfer between care facilities leads to fragmentation in care." To prevent this, new communication channels need to be more effective in improving communication. Before trying to enhance communication channels used between care facilities, locally and nationally, the current focus needs to be on communication channels used within care facilities. This is of great importance especially for patients and other stakeholders who deem it as the most critical health care item. The slow implementation of EHRs in small medical practices makes it difficult to improve and evaluate performance and to ensure the confidence of patients in new technologies. On the other hand, the lack of implementation in this area has a negative effect on other health care providers, e.g. hospitals which already implemented the system. Through the existing gap the delivery of health care information is not complete possible and does not help to make the system safer for users. Research Question: The main goal is to obtain an understanding of individual physicians' attitudes and barriers to EHR. The thesis will show the advantages and obstacles as well as the pros and cons for small- and medium-sized practices to adopt EHRs. Result: It is not necessary anymore to discuss if EHRs should be implemented. It is more important to discuss how they should implement. The main problem for implementation is the financial barrier for small medical practices as well as personal attitudes connected with the age distribution of physicians and patients.

Workflow issues related to adoption of the electronic health record (EHR) has led to unsafe workarounds, decreased productivity, inefficient clinical documentation and slow rates of EHR adoption. The problem addressed in this quality improvement project was nurses' lack of knowledge about workflow changes due to EHR adoption. The purpose of this project was to identify changes in workflow and to develop an educational module to communicate the changes. This project was guided by both the ADDIE model (analysis, design, development, implementation, and evaluation) and the diffusion of innovations theory. Five stages were involved: process mapping, cognitive walkthrough, eLearning module development, pilot study, and evaluation. The process maps and cognitive walkthrough revealed significant workflow changes particularly in clinical practice guidelines, emergency department treatment plan, and the interdisciplinary care plan. The eLearning module was developed to describe workflow changes using gamification, scenario-based learning, and EHR simulation. The 14-item course evaluation included a 6-point Likert scale and closed- and open-ended questions. A purposive sample of nurses (N = 30) from the emergency department and inpatient care areas were invited to complete the eLearning module and course evaluation. Data were collected until saturation was achieved (n = 15). Descriptive statistics revealed the participants' positive learning experience. This quality improvement project is expected to contribute to positive social change by facilitating the effective use of the new EHR which can improve the quality of patient care, promote patient safety, reduce healthcare costs, and improve patient outcomes.

Our ultimate goal as obstetric and neonatal care providers is to improve care for mothers and their babies. Continuous quality improvement (CQI) involves iterative cycles of practice change and audit of ongoing clinical care identifying practices that are associated with good outcomes. A vital prerequisite to this evidence based medicine is data collection. In Canada, much of the country is covered by separate fragmented silos known as regional reproductive care databases or perinatal health programs. A more centralized system which includes collaborative efforts is required. Moving in this direction would serve many purposes: efficiency, economy in the setting of limited resources and shrinking budgets and lastly, interaction among data collection agencies. This interaction may facilitate translation and transfer of knowledge to care-givers and patients. There are however many barriers towards such collaborative efforts including privacy, ownership and the standardization of both digital technologies and semantics. After thoroughly examining the current existing perinatal data collection among Perinatal Health Programs (PHPs), and the Canadian Perinatal Network (CPN) database, it was evident that there is little standardization of definitions. This serves as one of the most important barriers towards data sharing. To communicate effectively and share data, researchers and clinicians alike must construct a common perinatal language. Communicative tools and programs such as SNOMED CT® offer a potential solution, but still require much work due to their infancy. A standardized perinatal language would not only lay the definitional foundation in women’s health and obstetrics but also serve as a major contribution towards a universal electronic health record.

Η μηχανοργάνωση των φορέων υγείας αποτελεί προαπαιτούμενο για τη βελτίωση των παρεχόμενων υπηρεσιών τους ως προς τους πολίτες. Αν και η διεργασία έχει καθυστερήσει σημαντικά, φαίνεται πως οι εμπλεκόμενοι έχουν αντιληφθεί τη σπουδαιότητα της και πλέον ήδη βρίσκονται σε εξέλιξη προγράμματα προς αυτή την κατεύθυνση. Η ορθοπαιδική κλινική του ΠΓΝΠ, αποτελεί υπόδειγμα στο συγκεκριμένο τομέα καθώς ήδη από δεκαετίας έχει ηλεκτρονικό αρχείο με βασικά στοιχεία των ασθενών που νοσηλεύτηκαν, ενώ το 2005 πήγε ένα βήμα παραπέρα και επέκτεινε τη μηχανοργάνωση της με ηλεκτρονικό φάκελο υγείας ασθενή, εντάσοντας και τις απεικονιστικές εξετάσεις. Στο παρόν κείμενο στην εισαγωγή γίνεται μια ανάλυση της υπάρχουσας κατάστασης και μια λεπτομερής περιγραφή των προγραμμάτων που βρίσκονται σε εξέλιξη σχετικά με το θέμα. Δίνεται μια εξήγηση για την υστέρηση που έχει παρουσιαστεί και τα προβλήματα που αντιμετωπίζουν ανάλογα εγχειρήματα. Στην ενότητα 4 περιγράφεται σε γενικές γραμμές η εφαρμογή (λογισμικό) που εγκαταστάθηκε στην ορθοπαιδική κλινική και πως αυτή μηχανογραφεί της λειτουργικές διαδικασίες που ακολουθούνται στην καθημερινότητα του τμήματος. Στην επόμενη ενότητα η αναφορά εστιάζει περισσότερο στο “μικρόκοσμο” της κλινικής. Μιλάει με στατιστικά στοιχεία για το προσφερόμενο έργο της και ουσιαστικά αναλύει τον τρόπο με τον οποίο έγνε η εφαρμογή της μηχανοργάνωσης. Πώς ξεπεράστηκαν προβλήματα, τι χειρισμοί έγιναν με το προσωπικό, τι διαρθωτικές αλλαγές έγιναν ώστε να δημιουργηθεί ένα νέο τμήμα που ανέλαβε να κάνει το data entry. Η συνέχεια είναι με τις προοπτικές εξέλιξες οι οποίες χάρη σε μια θετική συγκυρία φαντάζουν εξαιρετικά ευοίωνες και στο τέλος παραθέτονται κάποια τεχνικά παραρτήματα που αφορούν περισσότερο το προσωπικό της κλινικής κι έχουν στόχο τη μετάδοση γνώσεων που θα βοηθήσουν στην εύρυθμη λειτουργία. / Computerization of health organizations consists precondition for the improvement of provided health services to citizens. Despite the process has an important delay, it seems the concerned parts are aware of the importance and projects aiming on this direction running already. The clinic of Orthopaedics at University Hospital of Patras, insists a positive sample in this sector. Since 90’s keeps a basic electronic database of patients’ data and in 2005 stepped forward adding health records and imaging platings (PAKS). Present thesis makes an analysis of present status and a description of relative projects in progress. An explanation for the hysteresis is given and solutions for past resolved problems. In chapter 4 presented the installed software in the clinic of Orthopaedics and how it is engaged with the procedures taking place in day life. In the next chapter the present thesis focuses on the clinic. It speaks in the language of statistics for the offered work towards the society and analysis the steps followed for the project of computerization. Finishing with the potential for evolution which seems to be very high thanks to a trend.