Background Health information exchange (HIE) may help healthcare professionals and policymakers make informed decisions to improve patient and population health outcomes. There is, however, limited uptake of HIE in many low- and middle-income countries (LMICs). While resource constraints are an obvious barrier to implementation of HIE, it is important to explore what other political, structural, technical, environmental, legal and cultural factors may be involved. In particular, it is necessary to understand associated barriers in relation to context-specific HIE processes and deployment strategies in LMICs with a view to discovering how these can be overcome. My home country Pakistan is currently struggling to implement HIE at scale and so I undertook a detailed investigation of these issues in the context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan and in LMICs more generally. Aims The concept of HIE is evolving both over time and by context. To gain a clearer understanding of this terrain, I began by identifying different definitions of HIE in the literature to understand how these had evolved and the underlying conceptual basis for these changes. Second, I sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore and understand in-depth stakeholders perspectives on the context of and deployment strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons for LMICs. Methods I undertook a phased programme of work. Phase 1 was a scoping review of definitions, which involved systematically searching the published literature in five academic databases and grey literature using Google to identify published definitions of HIE and related terms. The searches covered the period from January 1900 to February 2014. The included definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE in LMICs, I conducted a systematic review and searched for published and on-going (conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11 academic databases and looked for unpublished work through Google interface from January 1990 to July 2014. Eligible studies were critically appraised and then thematically analysed. Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE, and barriers and facilitators to its deployment. I also collected evidence through observational field notes and by analysing key international, national and regional policy documents. I used a combination of deductive thematic analysis informed by the theory of Diffusion of Innovations in Health Service Organisations that highlighted attributes of the innovation, the behaviour of adopters, and the organisational and environmental influences necessary for the success of implementation; and a more inductive iterative thematic analysis approach that allowed new themes to evolve from the data. The findings from these three phases of work were then integrated to identify potentially transferable lessons for Pakistan and other LMICs. Results In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven attributes emerged from the analysis that characterised HIE into two over-riding concepts. One was the ‘process’ of electronic information transfer among various healthcare stakeholders and the other was the HIE ‘organisation’ responsible to oversee the legal and business issues of information transfer. The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of 63 studies met the inclusion criteria. Low importance given to data informed decision making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack of feedback were considered to be major challenges to implementing HIE in LMICs, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, provide training for staff, assessing the needs of individuals and data standardisation all promoted implementation. The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case study. The complete dataset comprised of 39 interviews from 43 participants (including two group interviews), field observations, and a range of local and national documents. Findings showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and fragmented form. The district health information system was responsible for electronically transferring statistical data of public health facilities from districts to national offices via provincial intermediaries. Many issues were attributed to the absence of effective HIE, from ‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and facilitators to HIE were similar to the findings in Phase 2, but new findings included problems perceived to be the result of devolution of health matters from the federal to provincial governments, the politicised behaviour of international organisations, healthcare providers’ resistance to recording consultations to avoid liability and poor documentation skills. Public pressure to adopt mobile technology frameworks was found to be a novel facilitator whereas sharing regional health information with international organisations was perceived by some participants as disadvantageous as there were concerns that it may have enhanced espionage activities in the region. Conclusions HIE needs to be considered in both organisational and process terms. Effective HIE is essential to the provision of high quality care and the efficient running of health systems. Structural, political and financial considerations are important barriers to promoting HIE in LMICs, however, strong leadership, vision and policy direction along with financial support can help to promote the implementation of HIE in LMICs. Similarly, the federal and provincial governments could play an important role in implementing HIE in Pakistan along with the support of international organisations by facilitating HIE processes at federal and provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using leapfrog mobile technologies to facilitate care processes for local organisations and patients. Specifically, the study on Pakistan has highlighted that LMICs may achieve modest successes in HIE through use of patient held records and use of now ubiquitous mobile phone technology with some patient and organisational benefits, but scaling these benefits is dependent on the creation of national structures and strategies which are more difficult to achieve in the low advanced informatics skill and resource settings that characterise many LMICs.

As repercussões do trabalho na vida e na saúde do Homem há muito vêm sendo objeto de estudo na história da humanidade. No Brasil esta questão necessita ser melhor compreendida, principalmente após as recentes mudanças ocorridas na Constituição, onde observamos uma atenção maior ao capítulo da Saúde e, em especial, à Saúde do Trabalhador. A municipalização da saúde impõe mudanças profundas no lidar com estas questões. A informação fidedigna é pré-requisito básico para a efetivação de ações que visem a prevenção e a promoção de saúde. Para tanto delineamos como objeto de nosso trabalho o estudo da dinâmica da Comunicação do Acidente do Trabalho no município de Ribeirão Preto, no ano de 1996. Elegemos como método investigativo o estudo descritivo transversal da trajetória da notificação do Acidente do Trabalho e de suas repercussões, traçando um paralelo entre este sistema de notificação compulsória e o sistema utilizado pelo Serviço de Vigilância Epidemiológica, também compulsório. Os dados foram obtidos através da análise de documentos e da aplicação de entrevista semi-estruturada com representantes de todos os serviços envolvidos com o Acidente do Trabalho no município. Verificamos que na prática, apesar do preconizado legalmente, as transformações necessárias não foram efetivamente implementadas. O Sistema de Informações em Saúde do Trabalhador apresenta-se incompleto, persistindo um fluxo de Comunicações de Acidentes do Trabalho (CATs) fragmentado, não permitindo o desencadeamento de ações preventivas e de controle dos agravos. Ações conjuntas entre os níveis de atuação possíveis inexistem, não havendo uma interface entre as instituições. Em razão da precariedade das informações e da atual organização destes serviços, fica inviabilizada a execução de estudos epidemiológicos, diferentemente do que ocorre no sistema utilizado pelos Serviços de Vigilância Epidemiológica municípal. Faz-se necessário o enfrentamento desta problemática, de maneira a permitir a transformação do sistema de notificação dos Acidentes do Trabalho em instrumento eficaz à prevenção e à promoção de saúde. / The effect of work in the Man’s life and health has from long been object of studies in the human kind history. In Brazil, this point must be better understood, mainly after the recent changes occurred in the Brazilian Constitution, where we can see a greater attention to the Workman’s Health. The municipalization of the Health Service urges deep changes to deal with these items. The reliability of information is a basic pre-requisite for the rendering of actions the aim the prevention of diseases and the promotion of health. For this purpose, the object of our research is the study of the dynamics of the Communication of the Work Accident, in Ribeirão Preto, in the year of 1996. We chose as a researching method the transversal descriptive study of the process of notification of the work accident and its effects, comparing this type of compulsory notification with the as well compulsory system used by the Epidemiology Vigilance Service. The data was obtained upon the analysis of documents and the application of semi-structured interview with representatives of all the services involved with Work Accident in this town. We could observed that, in fact, despite legally advocated, the necessary changes were not effectively implemented. The Information System of the Workman Health Care shows incomplete, with a fragmented flux of Work Accidents Communications (WACs) what hinders the development of preventive actions, and the control of damages. No joiner proceedings are held between institutions. Due to the precariousness of information and to the present organization of this service, evident is the unfeasibility of the execution of epidemiologic studies, different from what happens in the system used by the Municipal Epidemiology Service. It’s urgent, therefore, to face this problem, in order to transform the system of notification of work accidents into an efficient instrument of health promotion and prevention.

Objetivo: Desenvolver um sistema de distribuição de conteúdo por meio de mensagens curtas de texto por celular (SMS - short message service) e avaliar se a utilização deste tipo de serviço direcionado a gestantes aumenta a adesão às práticas recomendadas de cuidado pré-natal. Desenho: Ensaio clínico controlado aleatorizado por conglomerados. Local do estudo: 20 unidades básicas de saúde (UBSs) de Ribeirão Preto, Brasil. População: Mulheres com mais de 18 anos, em seguimento de pré-natal nas UBSs selecionadas, com até 20 semanas de gestação no período de recrutamento. Métodos: Foi desenvolvido e implantado um sistema de informação e comunicação em saúde capaz de distribuir automaticamente conteúdo relevante para gestantes no período de pré-natal e pós-parto, o SISPRENACEL. Apesar de construído utilizando as boas práticas em engenharia de software e seu uso ter sido monitorado de perto, o sistema em si não foi avaliado neste trabalho. Para avaliar o impacto da intervenção, foram selecionadas as 20 UBSs que apresentaram os maiores números de gestantes nos anos anteriores. As UBS foram aleatorizadas em 2 grupos de 10 unidades para receber a intervenção e servir como controle. Em cada UBS alocada para receber a intervenção foram afixados cartazes convidando as gestantes a receber um pacote de SMS com conteúdo relacionada a gestação e ao parto (PRENACEL). Também nestas unidades, cada gestante recebeu uma filipeta reiterando o convite e com informações sobre o PRENACEL. As mulheres que se interessaram pelo projeto foram avaliadas quanto sua elegibilidade, forneceram consentimento e então passaram a receber as SMS, enviadas automaticamente pelo SISPRENACEL, durante a gestação em adição ao cuidado pré-natal de rotina. Nenhuma intervenção foi realizada nas UBS do grupo controle e as gestantes daquele grupo receberam apenas o cuidado pré-natal de rotina. As gestantes advindas dos dois grupos foram entrevistadas nas maternidades participantes após o parto. Principal medida de desfecho: A proporção de mulheres que apresentaram uma alta cobertura de práticas recomendadas durante o cuidado pré-natal, avaliada por um escore de cuidados (EC). Resultados: 350 mensagens demonstrando interesse em participar do PRENACEL foram recebidas e 157 mulheres elegíveis foram cadastradas pelo sistema. Durante o pré-natal foram enviadas 21.703 mensagens IX programadas, 1087 mensagens foram recebidas contendo dúvidas, sugestões ou comentários do serviço e 1230 mensagens foram enviadas em resposta as gestantes. Um total de 1210 mulheres elegíveis para participar do estudo recebeu cuidado pré- natal nas UBS participantes do projeto e tiveram seus desfechos avaliados nas maternidades participantes, sendo 770 oriundas das unidades intervenção e 440 das unidades controle. 157 mulheres elegíveis para receber a intervenção se interessaram pelo PRENACEL (20.4%, 157/770) e 73.9% delas (116/157) receberam e acessaram o pacote de mensagens. Houve desbalanço entre algumas características de base entre os grupos estudados e, em que pese o escore médio de cuidados pré-natais do grupo Intervenção ter sido maior que a do grupo Controle [46,6 (±8,0) vs 45,2 (±8,7), p=0,0002], a análise ajustada de intenção de tratamento não demonstrou diferença nos resultados entre os grupos intervenção e controle para a ocorrência de um alto escore de cuidados pré-natais. A análise por protocolo (bruta e ajustada para características sociodemográficas) sugere benefício da intervenção (RR ajustado para um alto escore de cuidados pré-natais: 1,12 (IC95%1,05-1,21)). Houve maior frequência de realização de 6 ou mais consultas (96,9% vs. 84,8%, p=0,01) e de exames para Sífilis (40,5% vs. 24,8%, p=0,03) e HIV (46,6% vs. 25,7%, p=0,0006) no grupo PRENACEL que no controle. A proporção de gestantes com alto EC foi maior no PRENACEL que no Controle (94% vs. 80%, p<0,0001). O NNT foi de sete mulheres recebendo a intervenção para uma mulher adicional com um alto escore de cuidados pré-natais. Conclusões: A utilização de um sistema de distribuição de conteúdo relevante foi essencial para o gerenciamento do volume e controle das mensagens distribuídas. Houve aumento de adesão aos cuidados recomendados durante este período, particularmente às consultas pré-natais e a triagem sorológica para sífilis e HIV entre as mulheres que receberam e acessaram o conteúdo enviado por SMS. É necessário desenvolver uma estratégia de implementação capaz de maximizar o interesse das mulheres em receber um pacote de SMS com conteúdo relacionada a gestação e parto. / Objective: Increase adherence to recommended practices of prenatal care through the development and use of a system that distributes content to pregnant woman through short message service (SMS). Design: Cluster randomized controlled trial. Setting: 20 primary health care facilities (PHCF) in Ribeirão Preto, São Paulo, Brazil. Subject: Women older than 18 years, attending to prenatal care on selected facilities, and that had 20 weeks of gestational age or less during recruitment time. Methods: We developed and deployed an information system to automatically distribute relevant content to pregnant women during prenatal and postnatal care, called SISPRENACEL. The system itself was not evaluated, although we built it using the best practices of software engineering and it was closely monitored. To evaluate the intervention\'s impact, we selected 20 PHCF that presented the highest number of pregnant women in previous years. We randomized the PHCF in 2 groups with 10 facilities to receive the intervention and 10 to be in the control group. We pinned posters in each one of the PHCF allocated to receive the intervention, inviting the women to subscribe to our service (PRENACEL), which would send them a SMS package with pregnancy and delivery related content. The women attending to an intervention facility received also a flyer that reinforced the invitation and that showed more information about PRENACEL. We evaluated the interested women to verify their eligibility and to get their consent. From this moment onwards, they started to receive SMS automatically sent by SISPRENACEL in addition to standard prenatal care. We did not do any intervention on PHCF allocated in the control group and the pregnant women in this group received standard prenatal care. We interviewed pregnant women coming from both groups in the selected maternities after delivery. Main outcome: Proportion of high level of coverage in recommend practices during prenatal care, evaluated by a score of care (SC). Results: SISPRENACEL received 350 messages of pregnant women interested in enrolling into PRENACEL and 157 eligible women were registered in the system. During prenatal period, SISPRENACEL sent 21.703 scheduled SMS, received 1087 with questions, suggestions or comments about the service and sent 1230 answers. We screened 1210 eligible women coming from the selected facilities and evaluated the outcome in the maternities, 770 women were from intervention facilities and 440 from control facilities. In the intervention group, 157 XI eligible women had shown interest in enrolling into PRENACEL (20.4%, 157/770) and 73.9% (116/157) received and accessed the package content. The basal characteristics between the groups were unbalanced and also the average score of prenatal care practices was higher in the Intervention group compared to the control group [46,6 (±8,0) vs 45,2 (±8,7), p=0,0002], the intention to treat adjusted analyses did not show difference between the intervention and control group to the high level of care. The protocol analyses (brute and adjusted for socialdemographics characteristics) suggested a vantage of the intervention (adjusted RR to a high score of prenatal care: 1,12 (IC95%1,05-1,21)). There was a higher frequency of attendance in 6 or more appointments (96,9% vs. 84,8%, p=0,01) and exams for syphilis (40,5% vs. 24,8%, p=0,03) and HIV (46,6% vs. 25,7%, p=0,0006) in PRENACEL group compared to control group. The proportion of pregnant women with high SC was higher in PRENACEL group than in the control group. The NNT was 7 women receiving the intervention to an additional woman with high level of prenatal care practices. Conclusions: The use of a system to distribute relevant content was essential to manage the volume and control of the SMS. There was an increase of adherence to recommended prenatal practices during this time, especially related to prenatal appointments, screening of syphilis and HIV between women that received and accessed the content sent through SMS. Discussion: It is necessary to develop a strategy for an implementation capable of maximize the women interest in receiving the SMS package with the pregnancy and delivery content.

Desde 1980 observa-se um crescente registro de ocorrências de causas externas no Brasil, que passaram a ocupar o segundo lugar dentre as causas de morte em grandes centros urbanos, superando as neoplasias. Foram analisados os dados de pacientes vítimas de trauma com internação na Unidade de Emergência do HCFMRP, em Ribeirão Preto (SP) entre 2006 e 2009. Foi realizada uma análise descritiva, envolvendo informações sobre o evento traumático, índices de gravidade RTS, ISS e TRISS, provenientes do software IntegraVep, de uso do Núcleo Hospitalar de Epidemiologia do HCFMRP, além de quantificações de exames laboratoriais e radiológicos demandados aos referidos pacientes, com o intuito de analisar as características e evolução dos pacientes. Foi possível observar a alta quantia de exames radiológicos e laboratoriais solicitados para pacientes com lesões leves além da distribuição dos pacientes quanto a faixa etária, sexo, mecanismos de trauma e gravidade de lesão. A utilização de um software específico para análise dos dados existentes no banco de dados do HCRP se mostrou adequada ao ser usado para os pacientes vítimas de trauma, podendo ser expandido para os demais setores do hospital. / Since 1980 there has been a growing record of occurrences of external causes in Brazil, which now occupy the second place among the causes of death in large urban centers, beating cancer. We analyzed the data of trauma patients with admission to the Emergency Unit of HCFMRP in Ribeirão Preto (SP) between 2006 and 2009. We performed a descriptive analysis, involving information about the traumatic event, severity indices RTS, ISS and TRISS, from the IntegraVep software, use of the Center for Hospital Epidemiology of HCFMRP, and quantitions of laboratory and radiological defendants to those patients with the aim of analyzing the characteristics and outcomes of patients. It was possible to observe the high amount of radiological and laboratory-only bid for patients with minor injuries and the distribution of patients by age, sex, mechanism of trauma and injury severity. The use of specific software for the analysis of existing data in the database of the HCRP was adequate to be used for trauma patients and can be expanded to other hospital departments.

O acompanhamento dos casos de Tuberculose (TB) envolve planejar ações assistenciais e gerenciais, as quais preveem a utilização de diferentes instrumentos de registro e sistemas de informação. Dessa forma, desenvolveu-se um sistema de informação para acompanhamento dos doentes de TB (SISTB), sendo que o presente estudo teve como objetivo analisar a implantação e utilização de tal sistema em um Ambulatório de Referência (AR) para o tratamento da TB de Ribeirão Preto - SP no período de 2013 à 2016. Trata-se de um estudo epidemiológico descritivo-analítico, do tipo intervenção, com abordagem quantitativa. Para análise do processo de implantação do SISTB, foi realizada observação com roteiro. O banco de dados do SISTB foi consultado para analisar a utilização e completude de preenchimento dos dados. Resultados: adaptações foram realizadas no SISTB para atender as necessidades dos profissionais de saúde. O cadastro dos doentes no sistema ocorreu em média 7 dias após o início do tratamento. O cadastro das supervisões medicamentosas e a edição de dados foram as ações mais realizadas. Fragilidades na completude dos dados foram identificadas no preenchimento do CPF, número do SINAN e na data do exame de cultura de escarro. Apresentaram 100% de completude o número do prontuário, endereço, município, data de nascimento, serviço que descobriu o caso, data de notificação, unidade de atendimento médico, unidade de supervisão medicamentosa, data de início do tratamento, tipo de tratamento, realizou tratamento anterior, data da alta e desfecho do tratamento. Conclusão: a utilização do SISTB possibilitou a geração automática da Ficha de Registro do Tratamento Diretamente Observado (TDO) e Boletim de Acompanhamento Mensal. Apesar da incompletude no preenchimento de alguns dados, outros foram completamente preenchidos. Foram identificados problemas que dificultavam o uso do SISTB, os quais foram corrigidos. O SISTB permitiu agrupar diferentes registros em um único local com acesso online, facilitando o compartilhamento e visualização de informações entre os profissionais e serviços de saúde / The monitoring of tuberculosis (TB) cases involves planning care and management actions, which provide the use of different instruments registration and information systems. Thus, it was developed an information system for monitoring TB patients (SISTB), and the present study analyzed the implementation and use of this system in a reference outpatient clinic (AR) for TB treatment in Ribeirão Preto - SP from 2013 to 2016. This is a descriptive and analytical epidemiological study of type intervention with a quantitative approach. For analysis of SISTB deployment process, script with observation was performed. The SISTB database was consulted to analyze the data use, data fill completeness. Results: Improvements were made in SISTB to meet the needs of healthcare professionals. The registration system of the patients was on average 7 days after initiation of treatment. Registration of drug supervision and editing of data was the most performed actions. Weaknesses in the completeness of data were identified for completion of the CPF, SINAN number and date of sputum culture test. Showed 100% completion of the medical record number, address, city, date of birth, service that discovered the case, notification, medical care unit, drug supervision unit, starting date of treatment, type of treatment, being treated earlier, date of discharge and treatment outcome. Conclusion: The use of SISTB enabled the automatic generation of Treatment Registration Form Directly Observed (TDO) and Monthly Monitoring Bulletin. Despite the incompleteness in filling some data, others were completely filled. Problems were identified that hindered the use of SISTB, which were corrected. The SISTB allowed group different records in a single location with online access, facilitating the sharing and visualization of information between professionals and health services

Trata-se de um estudo que teve como proposta utilizar os dados do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) como medida complementar para a identificação de mortes maternas não informadas. Foram investigados os Estados de São Paulo, Paraná, Pará, Ceará e Mato Grosso, nos anos de 1999 e 2000. Foram utilizados dados secundários dos CD-ROMs Movimento de Autorização de Internação Hospitalar do Sistema Único de Saúde (SUS), em seus arquivos reduzidos, por meio de formulários das AIHs que constituem o banco de dados informatizado e processado nacionalmente pelo SIH-SUS. Os resultados desta investigação possibilitaram identificar 651 mortes, sendo que 596 foram informadas pelo SIH-SUS como mortes maternas e 55 foram mortes maternas mascaradas ou presumíveis, obtidos a partir de procedimentos obstétricos e diagnósticos secundários pertencentes ao Capítulo XV da CID 10 - Gravidez, parto e puerpério, registrados no SIH-SUS. O presente estudo revelou que tal sistema de informação pode ser utilizado como medida complementar para a identificação de mortes maternas não informadas. / This study aimed at using data from the Hospital Information System of the Unified Health System (SIH-SUS) as a complementary measure for the identification of unreported maternal deaths. The states of São Paulo, Paraná, Pará, Ceará and Mato Grosso were investigated for years 1999 and 2000. Secondary data from CD-ROMs for Reports of Hospitalization Authorizations (AIH) of the Unified Health System (SUS) in reduced files were used through AIH forms comprising the database of computerized data which is nationally processed by SIH-SUS. The results of this investigation enabled the identification of 651 deaths, of which 596 were reported by SIH-SUS as maternal deaths and 55 were disguised or presumable maternal deaths obtained from obstetric procedures and secondary diagnoses according to Chapter XV of the International Classification of Diseases 10 - Pregnancy, delivery and puerperium recorded by SIH-SUS. This study showed that this information system can be used as a complementary measure for the identification of unreported maternal deaths.

This research examined if there is a relationship between engagement in quality improvement (QI) and health information technology (HIT) for local health departments (LHDs) controlling for workforce, finance, population, and governance structure. This was a cross-sectional study that analyzed data obtained from the Core questions and Module 1 in the NACCHO 2010 Profile of LHDs. Descriptive statistics, bivariate analyses, and logistic regression analyses were conducted. Findings suggest that LHD engagement in QI has a relationship with utilization of HIT including electronic health records, practice management systems, and electronic syndromic surveillance systems. This study provides baseline information about the HIT use of LHDs. LHDs and their system partners (hospitals, federally qualified health centers, and primary care providers) that utilize HIT as part of their QI decision making may have an easier time of using data to support evidence-based decision making and implementing the provisions of the Patient Protection and Affordable Care Act of 2010 in order to achieve population health for all.

The purpose of this study was to identify the effects of the prospective payment system on coding practices, resource allocations, quantitative and quantitative standards and organizational structure in medical record departments of 108 acute care, general medical and surgical hospitals in Kentucky. The study results revealed changes in coding practices consistent with the demand under the prospective payment system for more timely, complete and accurate information for billing purposes. Additionally, accurate data were needed to establish a reliable case-mix data base upon which future reimbursement formulas would be based. Increases in human and capital resources, especially in the area of software purchases to enhance the coding function were documented. Standards to measure coding quality and quantity had not been consistently developed in Kentucky hospitals. Use of developed coding standards for performance evaluation of coders was not widespread. Activities to optimize reimbursement 'ere employed by hospitals mostly on a concurrent basis. An organizational shift of the medical record department responsibilities to the finance area was not documented. However, a greater interdependence and cooperative relationship occurred between medical records, finance, administration and the medical staff.

Presently, self-tracking applications are used to help patients with chronic illness management. For example, applications ask users to track mood through online diaries or snap photos of their food content in order to analyze patterns correlated to their chronic disease. Although these health care applications are on the market today, there still exists a fundamental challenge in motivating participants to consistently update and enter information. Therefore, the focus of this thesis is on reducing the fatigue from using these applications. Pulling from user social media data will almost completely eliminate the capture burden placed on participants, since users will only have to continue to use social media as they regularly do. Instead of analyzing manually inputted data, patterns can be found between social media data and chronic diseases. A Microsoft Research team found indicators in public user Twitter data associated with the onset of a depressive episode. They were able to create a predictor tool, predicting the onset of a depressive episode, with 70 percent accuracy. Using this research alongside expert feedback, our aim is to design an interface used by both clinician and patient that will provide them with a timeline marking spikes in Twitter indicators correlated to a patient’s depressive episode.

Acute kidney injury (AKI) is a significant adverse effect of many medications that leads to increased morbidity, cost, and mortality among hospitalized patients. Recent literature supports a strong link between empiric combination antimicrobial therapy and increased AKI risk. As briefly summarized below, the following chapters describe my research conducted in this area. Chapter 1 presents and summarizes the published literature connecting combination antimicrobial therapy with increased AKI incidence. This chapter sets the specific aims I aim to achieve during my dissertation project. Chapter 2 describes a study in which patients receiving vancomycin (VAN) in combination with piperacillin-tazobactam (TZP) or cefepime (CFP). I matched over 1,600 patients receiving both combinations and found a significantly lower incidence of AKI among patient receiving the CFP+VAN combination when controlling for confounders. The conclusion of this study is that VAN+TZP has significantly increased risk of AKI compared to CFP+VAN, confirming the results of previous literature. Chapter 3 presents a study of patients receiving VAN in combination with meropenem (MEM) or TZP. This study included over 10,000 patients and used inverse probability of treatment weighting to conserve data for this population. After controlling for confounders, VAN+TZP was associated with significantly more AKI than VAN+MEM. This study demonstrates that MEM is clinically viable alternative to TZP in empiric antimicrobial therapy. Chapter 4 describes a study in which patients receiving TZP or ampicillin-sulbactam (SAM) with or without VAN were analyzed for AKI incidence. The purpose of this study was to identify whether the addition of a beta-lactamase inhibitor to a beta-lactam increased the risk of AKI. This study included more than 2,400 patients receiving either agent and found that there were no differences in AKI among patients receiving SAM or TZP; however, AKI was significantly more common in the TZP group when stratified by VAN exposure. This study shows that comparisons of TZP to other beta-lactams without beta-lactamase inhibitors are valid. Chapter 5 presents a study of almost 30,000 patients who received combination antimicrobial therapy over an 8-year period. This study demonstrates similar AKI incidence to previous literature and the studies presented in the previous chapters. Additionally, the results of the predictive models suggest that further work in this research area is needed. The studies conducted present a clear message that patients receiving VAN+TZP are at significantly greater risk of AKI than alternative regimens for empiric coverage of infection.