This thesis address one of the most important topics for the human being; health. Specifically, the research is about the deficiencies of the health system in Mexico. This paper shows the importance, how the system works and its current situation in the country. The purpose of this research is, based on the Pareto principle (20% vs 80%), to find how to solve most problems with the least possible investment.   It was found that the common denominator in the problems was the process and flow of information of the patients; specifically, the health records. The researchers address the issue at first explaining in a deep way the health records to highlight their importance in the health care system. In order to corroborate this finding in the literature; The researchers designed an interview, which was applied to physicians from the two main health institutions in Mexico in order to collect the necessary information to develop the thesis.   Since the design of the research is qualitative; the necessary social context is given to be able to understand the analysis and the results; likewise, the authors explain in detail the methodology used.   In spite of other important factors that were found such as the lack of results despite the investment and deficiencies in the infrastructure; It was concluded that, in fact, most of the problems were derived from the problems of health records. These results are important because it gives a parameter of what must be corrected first in order to have the expected results and a better health system.

Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

The United States health-care system is considered to be unsustainable due to its unbearably high cost. Many of the resources are spent on acute conditions rather than aiming at preventing them. Preventive medicine methods, therefore, are viewed as a potential remedy since they can help reduce the occurrence of acute health episodes. The work in this dissertation tackles two distinct problems related to the prevention of acute disease. Specifically, we consider: (1) early detection of incorrect or abnormal postures of the human body and (2) the prediction of hospitalization due to heart related diseases. The solution to the former problem could be used to prevent people from unexpected injuries or alert caregivers in the event of a fall. The latter study could possibly help improve health outcomes and save considerable costs due to preventable hospitalizations. For body posture detection, we place wireless sensor nodes on different parts of the human body and use the pairwise measurements of signal strength corresponding to all sensor transmitter/receiver pairs to estimate body posture. We develop a composite hypothesis testing approach which uses a Generalized Likelihood Test (GLT) as the decision rule. The GLT distinguishes between a set of probability density function (pdf) families constructed using a custom pdf interpolation technique. The GLT is compared with the simple Likelihood Test and Multiple Support Vector Machines. The measurements from the wireless sensor nodes are highly variable and these methods have different degrees of adaptability to this variability. Besides, these methods also handle multiple observations differently. Our analysis and experimental results suggest that GLT is more accurate and suitable for the problem. For hospitalization prediction, our objective is to explore the possibility of effectively predicting heart-related hospitalizations based on the available medical history of the patients. We extensively explored the ways of extracting information from patients' Electronic Health Records (EHRs) and organizing the information in a uniform way across all patients. We applied various machine learning algorithms including Support Vector Machines, AdaBoost with Trees, and Logistic Regression adapted to the problem at hand. We also developed a new classifier based on a variant of the likelihood ratio test. The new classifier has a classification performance competitive with those more complex alternatives, but has the additional advantage of producing results that are more interpretable. Following this direction of increasing interpretability, which is important in the medical setting, we designed a new method that discovers hidden clusters and, at the same time, makes decisions. This new method introduces an alternating clustering and classification approach with guaranteed convergence and explicit performance bounds. Experimental results with actual EHRs from the Boston Medical Center demonstrate prediction rate of 82% under 30% false alarm rate, which could lead to considerable savings when used in practice.

Nos últimos anos, a ciência e a tecnologia proporcionaram uma larga gama de ferramentas aos profissionais de saúde. Em especial, as Tecnologias da Informação, pois favorecem o aprimoramento considerável da qualidade dos serviços de saúde prestados à população, quando gerenciadas adequadamente. O objetivo deste estudo foi identificar a relação entre risco de desenvolvimento de lesão por pressão e complexidade assistencial em pacientes críticos internados na unidade de terapia intensiva de um hospital universitário por meio dos registros eletrônicos de saúde. Trata-se de estudo correlacional, longitudinal e descritivo, com abordagem quantitativa. A coleta de dados foi conduzida durante 120 dias, a amostra foi composta por 74 pacientes que atenderam aos critérios de inclusão da pesquisa. Em relação às características sociodemográficas e clínicas, foi observado maioria do sexo masculino (56,8%), brancos (73%), na faixa etária de 60 a 79 anos (40,5%) e o tempo médio de internação nessa unidade correspondeu a 10,5 dias. A maioria dos indivíduos apresentou risco elevado para a lesão por pressão com média de 11,7%, complexidade assistencial média foi de 84,7% e frequência média diária de 5,5% reposicionamentos, registrados no sistema de informação hospitalar. Quanto ao desfecho dos pacientes, 28 (37,8%) apresentaram lesão por pressão notificada no sistema de informação hospitalar, 27 (36,5%) evoluíram para óbito na Unidade de Terapia Intensiva e 15 (20,3%) evoluíram a óbito e desenvolveram lesão por pressão, mostrando uma associação estatisticamente significante (p= 0,017). Foi observado significância estatística (p<0,001) e relação inversa para a complexidade assistencial e risco para desenvolvimento. As variáveis complexidade assistencial, risco para desenvolvimento de lesão por pressão, posições observadas foram registradas e também frequência de reposicionamento foram coletadas 776 vezes e observou-se que 605 (78%) da amostra em relação ao escore de complexidade assistencial foram registradas. Em 50% dos dias que os profissionais de enfermagem foram escalados com um paciente identificou-se que não foi atingida a capacidade máxima de trabalho do mesmo. No entanto, foi possível identificar que a capacidade máxima foi ultrapassada quando os profissionais assumiram o segundo paciente, ocorrendo uma possível sobrecarga de trabalho em 75% dos dias. Foi possível identificar diariamente os registros inexistentes dos escores relacionados à complexidade assistencial, risco para o desenvolvimento de lesão por pressão e reposicionamento. Portanto, esta pesquisa evidencia a relevância dos dados e informações produzidas pela equipe de enfermagem para identificar os pacientes em risco, estabelecer medidas preventivas para os mesmos e consequentemente melhorar os indicadores de qualidade por meio dos registros eletrônicos e, assim, superar os desafios relacionados a segurança, qualidade e efetividade da assistência de enfermagem / In recent years, science and technology have provided a wide range of tools to health professionals. In particular, information technology, because they favor the improvement of quality of considerable health care provided to the population, when properly managed. The aim of this study was to identify the relationship between risk of pressure injury development and complexity care in critically ill patients admitted to the intensive care unit of a university hospital through electronic records. This is a longitudinal and correlational descriptive study with quantitative approach. Data collection was conducted for 120 days; the sample was composed of 74 patients who met the inclusion criteria. In relation to the sociodemographic and clinical characteristics, it was observed mostly male (56.8%), white (73%), aged 60 to 79 years (40.5%) and the average time of staying in this unit was 10.5 days. The majority of individuals presented a high risk for pressure injury with an average of 11.7%, average complexity care was 84.7% and average daily frequency of replacement registered was 5.5%, on the hospital information system. As for the outcome of patients, 28 (37.8%) had notified pressure injury in the hospital information system, 27 (36.5%) evolved to death in the intensive care unit and 15 (20.3%) evolved to death and developed pressure injury, showing a statistically significant association (p=0.017). Statistical significance was observed (p < 0.001) and inverse relationship to the complexity and risk to development assistance. The variables care complexity, risk for pressure injury development, positions observed, recorded and also repositioning frequency were collected 776 times and it was observed that 605 (78%) of the sample in relation to the care complexity scores were recorded. In 50% of the days that the nursing professionals have been scaled with a patient identified that was not achieved the maximum working capacity of the same. However, it was possible to identify the maximum capacity was exceeded when the professionals took the second patient, a possible overload of work in 75% of the days. It was possible to identify daily non-existent records of scores related to complexity, risk for pressure injury development and repositioning. Therefore, this research highlights the importance of data and information produced by the nursing staff to identify patients at risk, establish preventive measures to the same and consequently improve the quality indicators by means of electronic records and thus overcome the challenges related to safety, quality and effectiveness of nursing care

A personal health record (PHR) contains health data about a patient, which is maintained by the patient. Patients may share their PHR data with a wide range of users such as healthcare providers and researchers through the use of a third party such as a cloud service provider. To protect the confidentiality of the data and to facilitate access by authorized users, patients use Attribute-Based Encryption (ABE) to encrypt the data before uploading it onto the cloud servers. With ABE, an access policy is defined based on users' attributes such as a doctor in a particular hospital, or a researcher in a particular university, and the encrypted data can only be decrypted if and only if a user's attributes comply with the access policy attached to a data object. Our critical analysis of the related work in the literature shows that existing ABE based access control frameworks used for sharing PHRs in a storage cloud can be enhanced in terms of scalability and security. With regard to scalability, most existing ABE based access control frameworks rely on the use of a single attribute authority to manage all users, making the attribute authority into a potential bottleneck regarding performance and security. With regard to security, the existing ABE based access control frameworks assume that all users have the same level of trust (i.e. they are equally trustworthy) and all PHR data files have the same sensitivity level, which means that the same protection level is provided. However, in our analysis of the problem context, we have observed that this assumption may not always be valid. Some data, such as patients' personal details and certain diseases, is more sensitive than other data, such as anonymised data. Access to more sensitive data should be governed by more stringent access control measures. This thesis presents our work in rectifying the two limitations highlighted above. In doing so, we have made two novel contributions. The first is the design and evaluation of a Hierarchical Attribute-Based Encryption (HABE) framework for sharing PHRs in a storage cloud. The HABE framework can spread the key management overheads imposed on a single attribute authority tasked with the management of all the users into multiple attribute authorities. This is achieved by (1) classifying users into different groups (called domains) such as healthcare, education, etc., (2) making use of multiple attribute authorities in each domain, (3) structuring the multiple attribute authorities in each domain in a hierarchical manner, and (4) allowing each attribute authority to be responsible for managing particular users in a specific domain, e.g. a hospital or a university. The HABE framework has been analyzed and evaluated in term of security and performance. The security analysis demonstrates that the HABE framework is resistant to a host of security attacks including user collusions. The performance has been analyzed in terms of computational and communication overheads and the results show that the HABE framework is more efficient and scalable than the most relevant comparable work. The second novel contribution is the design and evaluation of a Trust-Aware HABE (Trust+HABE) framework, which is an extension of the HABE framework. This framework is also intended for sharing PHRs in a storage cloud. The Trust+HABE framework is designed to enhance security in terms of protecting access to sensitive PHR data while keeping the overhead costs as low as possible. The idea used here is that we classify PHR data into different groups, each with a distinctive sensitivity level. A user requesting data from a particular group (with a given sensitivity level) must demonstrate that his/her trust level is not lower than the data sensitivity level (i.e. trust value vs data sensitivity verification). A user's trust level is derived based on a number of trust-affecting factors, such as his/her behaviour history and the authentication token type used to identify him/herself etc. For accessing data at the highest sensitivity level, users are required to get special permissions from the data owners (i.e. the patients who own the data), in addition to trust value vs data sensitivity verification. In this way, the framework not only adapts its protection level (in imposing access control) in response to the data sensitivity levels, but also provides patients with more fine-grained access control to their PHR data. The Trust+HABE framework is also analysed and evaluated in term of security and performance. The performance results from the Trust+HABE framework are compared against the HABE framework. The comparison shows that the additional computational, communication, and access delay costs introduced as the result of using the trust-aware approach to access control in this context are not significant compared with computational, communication, and access delay costs of the HABE framework.

Background: Diabetes prevalence in Scotland is increasing at ~4.6% annually; 247,278 (4.7%) in 2011. My Diabetes My Way (MDMW) is the NHS Scotland information portal, containing validated educational materials for people with diabetes and their carers. Internet-based interventions have potential to enhance self-management and shift power towards the patient, with electronic personal health records (PHRs) identified as an ideal method of delivery. In December 2010, a new service was launched in MDMW, allowing patients across Scotland access to their shared electronic record. The following thesis aims to identify and quantify the benefits of a diabetes-focused electronic personal health record within NHS Scotland. Methods: A diabetes-focused, population-based PHR was developed based on data sourced from primary, secondary and tertiary care via the national diabetes system, Scottish Care Information - Diabetes Collaboration (SCI-DC). The system includes key diagnostic information; demography; laboratory tests; lifestyle factors, foot and eye screening results; prescribed medication and clinical correspondence. Changes are tracked by patients over time using history graphs and tables, data items link to detailed descriptions explaining why they are collected, what they are used for and what normal values are, while tailored information links refer individuals to facts related to their condition. A series of quasi-experimental studies have been designed to assess the intervention using subjectivist, mixed-methods approaches incorporating multivariate analysis and grounded theory. These studies assess patient expectations and experiences of records access, system usage and uptake and provide preliminary analysis on the impact on clinical process outcomes. Survey questionnaires were used to capture qualitative data, while quantitative data were obtained from system audit trails and from the analysis of clinical process outcomes before and after the intervention. Results: By the end of the second year, 2601 individuals registered to access their data (61% male; 30.4% with type 1 diabetes); 1297 completed the enrolment process and 625 accessed the system (most logins=346; total logins=5158; average=8.3/patient; median=3). Audit trails show 59599 page views (95/patient), laboratory test results proving the most popular (11818 accesses;19/patient). The most utilised history graph was HbA1c (2866 accesses;4.6/patient). Users are younger, more recently diagnosed and have a heavy bias towards type 1 diabetes when compared to the background population. They are also likely to be a more highly motivated ‘early adopting’ cohort. Further analysis was performed to compare pre- and post-intervention clinical outcomes after the system had been active for nearly two and a half years. Results of statistical significance were not forthcoming due to limited data availability, however there are grounds for encouragement. Creatinine tests in particular improved following 1 year of use, with type 1 females in particular faring better than those in patient other groups. For other clinical tests such as HbA1c, triglycerides, weight and body mass index improvements were shown in mean and/or median values.96% of users believe the system is usable. Users also stated that it useful to monitor diabetes control (93%), improve knowledge (89%) and enhance motivation (89%). Findings show that newly diagnosed patients may be more likely to learn more about their new condition, leading to more productive consultations with the clinical team (98%). In the pre-project analysis, 26% of registrants expressed concerns about the security of personal information online, although those who actually went on to use it reported 100% satisfaction that their data were safe. Engagement remains high. In the final month of year two, 44.6% of users logged in to the system. 55.3% of users had logged in within the previous 3 months, 78.9% within the previous 6 months and 91.4% within the previous year. Some legacy PHRs have failed due to lack of uptake and deficiencies in usability, so as new systems progress, it is essential not to repeat the mistakes of the past. Feedback: "It is great to be able to view all of my results so that I can be more in charge of my diabetes".Conclusion: The MDMW PHR is now a useful additional component for the self-management of diabetes in Scotland. Although there are other patient access systems available internationally, this system is unique in offering access to an entire national population, providing access to information collected from all diabetes-related sources. Despite its development for the NHS Scotland environment, it has the potential to connect to any electronic medical record. This local and domain-specific knowledge has much wider applicability as outlined in the recommendations detailed, particularly around health service and voluntary sector ownership, patient involvement, administrative processes, research activities and communication. The current project will reach 5000 patients by the end of 2013.

Ces travaux de thèse présentent une approche de pharmaco-épidémiologie explorant l'exposition médicamenteuse chez des patients atteints de lymphome tout au long de leur parcours de soin. L'utilisation des données du Système National d'Information Inter-régimes de l'Assurance Maladie (SNIIRAM) nous a permis de quantifier cette exposition médicamenteuse et de déterminer les facteurs associés dans le contexte de la vie réelle. Les travaux de recherche réalisés au cours de cette thèse répondaient à 3 objectifs. Dans un premier objectif, nous avons souhaité valider l'utilisation du SNIIRAM à des fins de recherche pour améliorer la robustesse des futures études menées sur le lymphome. Après avoir défini plusieurs algorithmes d'identification des cas incidents de lymphome, nous avons testé leur validité par confrontation aux données cliniques exhaustives du Registre des cancers du Tarn. Les paramètres de performance obtenus permettent de considérer les données disponibles dans le SNIIRAM comme un outil puissant pour mener des études pharmaco-épidémiologiques ou médico-économiques sur le Lymphome. Le second objectif était d'explorer l'existence d'une surconsommation de médicaments psychotropes au cours de la phase active de traitement par rapport à une population témoin, sous l'hypothèse d'une initiation accrue de ces médicaments pour pallier les complications psychologiques associées à la prise en charge du Lymphome. Par ailleurs, la chronicisation fréquemment observée de ce type de consommation peut conduire à terme à des complications potentiellement évitables. Pour répondre à cet objectif, nous avons réalisé une étude selon une approche " new-user design ", à partir d'une cohorte de patients incidents de lymphome identifiés dans les données du SNIIRAM à l'échelon régional. Nous avons observé un taux d'initiation supérieur au taux observé en population générale ou chez des patients atteints d'autres pathologies mettant en jeu le pronostic vital (infarctus du myocarde). En fonction de la classe thérapeutique étudiée, 20 à plus de 50% des patients restaient exposés de façon inappropriée (au-delà des recommandations) à ces médicaments. Le troisième objectif a donc été d'explorer les déterminants associés à une utilisation prolongée de médicaments psychotropes dans la phase de l'après-cancer à partir des données de l'Echantillon généraliste des bénéficiaires (EGB). [...] / This thesis presents a pharmacoepidemiology approach to describe drug utilization in lymphomas during their whole care pathway. The use of the French claims database (Système National d'Informations Inter-Régimes de l'Assurance Maladie (SNIIRAM)) allows to exhaustively quantify this drug utilization in real life conditions. This thesis consists of three mains objectives. First, we aimed to develop validated algorithms for the identification of incident cases of lymphoma. For the validation, we used data from a regional Cancer Registry as the gold standard. The purpose of this validation study was to enhance validity of future studies conducted on lymphomas in the SNIIRAM database. The results of this study associated to strengths of this database demonstrate that this approach is of great interest to conduct pharmacoepidemiological or medico-economic studies in lymphomas. Second, we aimed to estimate the incidence of use of psychotropic drugs during the active treatment phase of lymphoma in comparison with control groups. Indeed, the increased probability of developing anxio-depressive disorders after diagnosis could lead to an increased initiation of psychotropic drugs and a potential inappropriate chronic use of these drugs after initiation. Such inappropriate chronic use can unnecessarily expose patients to adverse event. For this aim, we conducted a new-user cohort study using data from the SNIIRAM database. The results of this study revealed that the initiation rate of these drugs is higher than in the general population or for life-threatening diseases such as myocardial infarction. Moreover, we observed an inappropriate prolonged use for a significant fraction of patients (20% to more than 50% according to therapeutic class). On the basis of these findings, the third objective was to identify factors associated with prolonged use of these drugs during survivorship. This study was conducted using data from the General Sample of Beneficiaries (EGB). [...]

The use of electronic health records (EHR) has the potential to improve relationships between physicians and patients and significantly improve care delivery. The purpose of this study was to analyze the relationships between hospital attributes and EHR implementation. The research design for this study was the cross-sectional approach. Secondary data from the Health Information and Management Systems Society (HIMSS) Analytics Database was utilized (n = 169) in a correlational crosssectional research design. Normalization Process Theory (NPT) and implementation theory were the theoretical underpinnings used in this study. Multiple linear regressions results showed statistically significant relationships between the 4 independent variables (region, ownership status, number of staffed beds [size], and organizational control) and the outcomes for the dependent variables of EHR software application attributes (Clinical Decision Support Systems (CDSS) components), EHR software application attributes (major systems), and successful implementation of Meaningful Use (MU) (p = .001). A statistically significant relationship (p = .001) was also found between the 2 independent variables (EHR software application attributes [CDSS components] and EHR software application attributes [major systems]) and the outcome of successful implementation of MU when combined. This evidence should provide policy makers and health practitioners support for their attempts to implement EHR systems to result in positive Meaningful Use which has been shown to be more cost effective and result in better quality of care for patients.The potential social change is improved medication prescribing and administration for hospitals and, lower cost and better quality of care for patients.

Many countries (especially developing countries) are plagued with critical healthcare issues such as chronic, infectious and pandemic diseases, a lack of basic healthcare programmes and facilities and a shortage of skilled healthcare workers. E-Health (healthcare based on the Internet technologies) promises to overcome some problems related to the reach of healthcare in remote communities. Electronic Health Record (EHR) (consisting of all diagnostic information related to a patient) forms the core of any E-Health system. Hence the success of an E-Health system is very much dependent on the success of the EHR systems. Although interest in automating the health record is generally high, the literature informs us that they do not always succeed in terms of adoption rate and/or acceptance, even in developed countries. The success of the adoption tends to be low for resource constrained (e.g. insufficient E-Health infrastructure) developing countries. As part of the effort to enhance EHR acceptance, readiness assessment for the innovation becomes an essential requirement for the successful implementation and use of EHR (and hence E-Health). Based on a thorough literature review, several research gaps have been identified. In order to address these gaps, this thesis (based on design science research methodology) presents E-Health Readiness Assessment Methodology (EHRAM). It involves a new E-Health Readiness Assessment Framework (EHRAF), an assessment process and several techniques for analysing the assessment data to arrive at a readiness score. The EHRAF (Model) integrates the components from healthcare providers?? and organisational perspectives of existing E-Health readiness evaluation frameworks. The process of EHRAM (Method) starts with the development of a set of hierarchical evaluation criteria based on EHRAF. This leads to the questionnaire development for data collection. The data is analysed in EHRAM using a number of statistical and data mining techniques. The instantiation part of the design science research involves an automated tool for the implementation of EHRAM and its application through a case study in a developing country.

Long waitlists and growing numbers of unattached patients are indicative of a Canadian healthcare system which is unable to address the demands of a growing and aging population. Health information technology is one solution offering respite, but brings its own issues. Health information technology includes primary care physician office systems, telehealth and jurisdictional EHRs integrated through interoperability standards to share data across care providers. This dissertation explores effects that health information technology has on primary care. Literature reviews provided context of health information systems adoption. Surveys and semi-structured interviews gathered information from health system actors. Workflow analysis illustrated how technology could change physician office workflow. Exam room observations illustrated how technology affects proxemics and haptics in the patient encounter. This research derived change management models which quantified substantial change management costs related to adoption of physician office systems. We found that physicians have concerns over how health information technology will affect efficiency, financial, quality, liability, safety and other factors. Physicians in smaller suburban physician offices take little time to select a system for their needs. Urban, academic and hospital physicians spend more time networking with colleagues and devote funds to project management and training. Our studies showed that stronger professional networks, more complete training, a managed approach to implementation and in-house technical support are more influential in facilitating adoption than remuneration models. Telemedicine can improve quality of care, the referral process for family physicians and access to services for patients. Teledermatology was shown to make significant improvements in access to services for patients, but referring physicians are concerned about their liability if they follow the recommendations of a dermatologist who has not seen their patient face-to-face. Certification organizations mitigate liability, procurement and financial risk to qualifying family physicians by pre-qualifying vendor solutions, coaching physicians through procurement and reimbursing family physicians for purchasing an approved system. We found that centralization plays a key role in adoption of health information systems at the jurisdictional and primary care level. Online scheduling can reduce human resource requirements used in scheduling, if the system is well implemented, well documented and easy to use. / Engineering Management