This thesis describes research into the facilitation of mediated communication of health updates and support needs across the social network, on behalf of individuals experiencing acute or chronic health problems. This led to the user-centred design, development and evaluation of a prototype software tool. Investigatory applied research was conducted with the parents of sick newborn infants who were (or had previously been) cared for in a Neonatal Unit, and their social networks of family, friends, colleagues and neighbours. The thesis makes contributions to knowledge within Social Networks, Health Informatics, Adaptive Systems and User Modelling. The user-centred research was conducted using a Grounded Theory approach, progressively focussing on developing themes. An iterative approach was taken to evaluation of the resulting theory. In the Social Networks domain, a novel, intuitive mechanism for capturing the membership and structure of an individual’s personal social network has been defined and developed, grounded in the work of evolutionary anthropologist Robin Dunbar. Use of the highly visual mechanism requires low levels of literacy and computer skills. It is cross-culturally applicable, and makes no prior assumptions about an individual’s relationships. In the domains of Health Informatics, Adaptive Systems and User Modelling, a model has been defined for adaptive information sharing across the personal social network. This model provides a number of new insights about information sharing choices made by an individual experiencing a health crisis (the ego) and their supporters (alters).

The National Health Planning and Resources Development Act. Public Law 93-641, the last major step in the regulation of the health care system, created a network of health system agencies and state level health planning agencies. Subsequent legislation, the Health Planning and Resources Development Amendment 1929, Public Law 96-79, amended 1974 Law and changed the role and function of health systems agencies to include more regulatory activities. By 1981, the activities of Health System Agencies were being curtained by the action of the Reagan administration. The Health promotion/wellness movement which seeks to improve health has been developing as a compliment to medical medicine for several years. Previous research has determined that health systems agencies were active in health promotion and identified several planning and implementation activities related to this involvement. This is a survey of health systems agencies to determine their efforts in healthy promotions. Resources allocated to these activities, and opinions of the director relevant to agency involvement in health promotion. All active healthy system agencies listed in the 1980. Directory of Health System Agencies (DHSH) were surveyed by a mailed questionnaire. Reponses were receive from 112 agencies (57%) and the respondents were found to be representative of the population. The results revealed health systems agencies to be involved in health promotion. More than 90 percent of the responders listed some type of health promotion activity in their Healthy System Plans for the 1979-1980 planning year. Approximately half of the responders reported some community activity in health promotion. The majority of executive directors saw health systems agencies as being only moderately effective in controlling health care costs: considered healthy promotion as a viable means of controlling health care cost: and believed that modifications of individual life-styles had the greatest potential for improving health status. The survey revealed that Healthy System Agencies did not restrict the wellness/health promotion activities to traditional health facilities, but were defining health broadly and working with a variety of agencies to develop services.

This project attempts to describe how a hospice and palliative care partnership program works. Through the assessment of one such program, the researcher sought to find out the essential components of the partnership including how the two partner organizations interact and work together. Data was collected using various methods: document review of organization documents such as newsletters, annual or quarterly reports, brochures and other available literature e.g. materials on organizations’ website and on social media; in-depth interviews with stakeholders of both organizations that included staff and board members; observation of staff working; and participant observation during organization events. The findings of the research shows that in order for organizations to have an effective partnership program in place, both partners need to have strong leadership in place, possess a willingness to learn from each other, maintain regular communication, and visit each other regularly. With this in place, several outcomes of the program are likely such as: increasing advocacy for hospice and palliative care, increasing visibility of the organizations both nationally and internationally, and provides an opportunity for organizations to network with other organizations in their locality in order to achieve partnership objectives. The study further reveals that global collaborations in the field of hospice and palliative care began with the advent of the international hospice movement. The assessment of this hospice partnership demonstrates how organizations can establish working relationships and the results likely to come out of such an initiative.

Wits Business School University of Witwatersrand Johannesburg, South Africa Master in Finance and Investment (2014) / Following decades of under-investment, gaps in Africa’s healthcare infrastructure are becoming disturbingly obvious. The interplay of governments’ fiscal policies of budget imbalance reduction and other political considerations present a seemingly insurmountable obstacle to overcoming the backlog in Africa’s healthcare infrastructure. The two main objectives of this study were to understand the sources of financing and the best way to structure the financing of healthcare infrastructure in Africa. Looking at financing arrangements in various industries; and how healthcare sectors in developed countries have been financed, the report draws on perspectives from the financiers on how the healthcare infrastructure gap should be filled in Africa. This study, which utilised survey questionnaires and in-depth interviews, identified government revenues, regional development banks, private equity and donor financing numbers as dominant funding sources for the financing of healthcare infrastructure in Africa. Further, the study explored various ways in which finance could be structured and found that within those various models of financing, donor financing and government revenue were statistically significant on structuring the finance, especially within public-private partnership arrangements. These include sale and lease back arrangements (p=0.0022), complete ownership of projects by the private sector (p=0.003), management operation contracts (p=0.00034) and other forms of PPPs. More perspectives were obtained on enablers and barriers to improving investability of the healthcare sector. Africa’s economic growth and the improving ease of doing business were major enablers for healthcare sector’s investability. However, the role played by government as both a financier and a regulator seemed a barrier. Some structural models that would need government back-up include subordinated debt; with pricing at marginal cost and matching risk and return recovered through the taxation system. The latter continues to characterise much of Africa’s publicly provided healthcare infrastructure. In conclusion, investments in healthcare may not be separated from a country’s level of financial deepening. As the sector develops, it then becomes possible to utilise the models aforementioned. It is recommended that any governments’ investments in healthcare be more catalytic, to unlock value that allows the private sector to compete, both as financiers and innovators in healthcare. Furthermore clear strategies on PPPs are urgently needed for healthcare in Africa including policy consistency in financing and regulating healthcare.

A research report submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, November 2015 / The aim of this study was to give an account of what it means to be a hospital consultant in a national health service that has been undergoing change for almost three decades. Classic grounded theory was used to identify the main concern of hospital consultants sampled for the study and how they resolved this concern on a routine basis. Data were obtained from three sources: interviews, observation and document analyses. Classic grounded theory procedures of constant comparison and theoretical sampling were used and Rolling with the Punches emerged as the pattern of behaviour through which the hospital consultants dealt with their main concern, which was managerialism. Rolling with the Punches involves four modes: Stabilising Temporarily, Resisting, Limiting the Impact and Adjusting to/Living with. The mode of behaviour was contingent on a central and on-going Weighing-up process, in which the hospital consultants used their personal narratives, beliefs and commitment structures to make sense of what was happening and what they could possibly do about it. Hence, the mode of behaviour was contingent, historicised and in flux. The Weighing-up process can set off triggers that can lead to a change of mode that need not be linear. Key words: doctors, managers, grounded theory, weighing up, stabilising temporarily, resisting, subverting, quibbling, limiting the impact, lying low, faking it, living with, adjusting to, going with the flow, complying, waiting it out. / MB2016

Significant out-of-pocket spending to afford medications to control blood glucose in elderly people with diabetes is one of the chief challenges to medication adherence. In an effort to reduce the financial burden of prescription drugs on the elderly, Medicare Part D was created and went into effect in 2006. However, one in four Medicare Part D beneficiaries experiences a coverage gap where they must pay 100% of total prescription drug costs. Approximately a quarter of those individuals discontinued their drugs when they reached the coverage gap. Currently, with the Patient Protection and Affordable Care Act of 2010, the coverage gap will be eliminated by 2020. This dissertation examines which factors affect medication adherence in adults with diabetes (Aim 1) and whether the recent policy effort of Medicare Part D effectively decreases the financial burden of prescription drugs on the elderly with diabetes (Aim 2). Chapter One provides the significance of out-of-pocket costs for medication adherence in elderly individuals with diabetes as well as background information on Medicare Part D and its coverage gap. Chapter Two reviews the literature to synthesize current knowledge that has informed the methodology for this dissertation. This chapter also identifies gaps in this body of work. These include comparing advantages and disadvantages of medication adherence as measured by patient self-report, pharmacy refills, and electronic lids on medication containers. Two systematic reviews are conducted in order to determine the most commonly used measurements and definitions of medication adherence measured by pharmacy claims data, and to identify barriers to and facilitators of medication adherence among adult diabetes patients. Lastly, previous studies that focused on the impact of Medicare Part D and its coverage gap on out-of-pocket pharmacy costs and medication adherence are reviewed. Chapter Three describes the methodologies to address Aims 1 and 2 including the study design, information on the data source, sample descriptions, a conceptual framework, study variables and analytic plans. Chapter Four presents key findings of this study, and Chapter Five concludes with summaries and interpretations of the findings, implications for practice and policy, and recommendations for future research.

The increasing adoption of electronic health records (EHRs) has led to an unprecedented amount of patient health information stored in an electronic format. The ability to comb through this information is imperative, both for patient care and computational modeling. Creating a system to minimize unnecessary EHR data, automatically distill longitudinal patient information, and highlight salient parts of a patient’s record is currently an unmet need. However, summarization of EHR data is not a trivial task, as there exist many challenges with reasoning over this data. EHR data elements are most often obtained at irregular intervals as patients are more likely to receive medical care when they are ill, than when they are healthy. The presence of narrative documentation adds another layer of complexity as the notes are riddled with over-sampled text, often caused by the frequent copy-and-pasting during the documentation process. This dissertation synthesizes a set of challenges for automated EHR summarization identified in the literature and presents an array of methods for dealing with some of these challenges. We used hybrid data-driven and knowledge-based approaches to examine abundant redundancy in clinical narrative text, a data-driven approach to identify and mitigate biases in laboratory testing patterns with implications for using clinical data for research, and a probabilistic modeling approach to automatically summarize patient records and learn computational models of disease with heterogeneous data types. The dissertation also demonstrates two applications of the developed methods to important clinical questions: the questions of laboratory test overutilization and cohort selection from EHR data.

The service industry has become increasingly competitive. This dissertation addresses a number of outstanding and fundamental questions of competitions in service operations and supply chains. The challenges are characterization of the equilibrium behaviors, estimating the impact of firms' interactions, and designing of efficient market mechanisms. The first chapter of this dissertation considers price competition models for oligopolistic markets, in which the consumer reacts to relative rather than absolute prices, where the relative price is defined as the difference between the absolute price and a given reference value. Such settings arise, for example, when the full retail price earned by the ``retailer" is reduced by virtue of a third party offering a subsidy or a rebate or in prospect theoretical models in which customers establish a reference price and base their choices on the differentials with respect to the reference price. When choosing among the various competing options, the consumer trades off the net price paid with various other product or service attributes, as in standard price competition models. The reference price may be exogenously specified and pre-announced to the competing firms. Alternatively, it may be endogenously determined, as a function of the set of absolute prices selected by the competing firms, for example the lowest or the second lowest price. We characterize the equilibrium behavior under a general reference value scheme of the above type; this in a base model, where we assume that the consumer choice model is of the general MultiNomialLogit (MNL) type. We also derive comparison results for the price equilibria that arise under alternative subsidy schemes. These comparisons have important implications for the design of subsidy schemes. The second chapter applies the results of the first chapter to the Medicare insurance market, both in terms of its existing structure, as well as in terms of various proposals to redesign the program. Based on an oligopoly price competition model tailored towards this market, and actual county-by-county data for the year 2010, we estimate the impact such reforms would have on the plans' market shares, equilibrium premia, the government's cost, and the out-of-pocket expenses of the beneficiaries. We employ two different methodologies to derive the parameters in the county-by-county competition models: (i) a calibration model, and (ii) parameter distributions obtained from models estimated in Curto et al. (2015). The predicted impacts on the above performance measures are remarkably consistent across the two methodologies and reveal, for example, that the government cost would decrease by 8% if the traditional fee-for-service(FFS) plans are kept out of competitive bidding process and by 16.5%-21% if they are part of the process. The third chapter studies a class of buy procurement mechanisms, framework agreements (FAs), that are commonly used by buying agencies around the world to satisfy demand that arises over a certain time horizon. We are one of the first in the literature that provides a formal understanding of FAs, with a particular focus on the cost uncertainty faced by bidders over the FA time horizon. We introduce a model that generalizes standard auction models to include this salient feature of FAs; we analyze this model theoretically and numerically. First, we show that FAs are subject to a sort of winner's curse that in equilibrium induces higher expected buying prices relative to running first-price auctions as needs arise. Then, our results provide concrete design recommendations that alleviate this issue and decrease buying prices in FAs, highlighting the importance of (i) monitoring the price charged at the open market by the FA winner and using it to bound the buying price; (ii) investing in implementing price indexes for the random part of suppliers' costs; and (iii) allowing suppliers the flexibility to reduce their prices to compete with the open market throughout the selling period. These prescriptions are already being used by the Chilean government procurement agency that buys US$2 billion worth of contracts every year using FAs. The fourth chapter considers the preference of contractual forms in supply chains. The supply chain contracting literature has focused on incentive contracts designed to align supply chain members' individual interests. A key finding of this literature is that members' preferences for contractual forms are often at odds: the upstream supplier prefers more complex contracts that can coordinate the supply chain; however, the downstream retailer prefers the wholesale price--only contract because it leaves more surplus (than a coordinating contract) that the retailer can get. This chapter addresses the following question: under what circumstances do suppliers and retailers prefer the same contractual form? We study supply chain members' preference for contractual forms in three different competitive settings in which multiple supply chains compete to sell substitutable products to the same market. Our analysis suggests that both upstream and downstream sides of the supply chains may prefer the same ``quantity discount'' contract, thereby eliminating the conflicts of interest that otherwise typify contracting situations. More interesting still is that both sides may also prefer the wholesale price--only contract, which offers a theoretical explanation to why the simple inefficient contract is widely adopted in supply chain transactions.

This dissertation examines the assessment and documentation of sexual orientation and gender identity in the home healthcare setting, specifically patient and nurse perceptions of such data collection, as well as what is documented in nurses’ narrative notes about patients’ sexual orientation and gender identity. Chapter One describes the problem of health disparities among lesbian, gay, bisexual and transgender (LGBT) patients and how lack of documentation contributes to this problem. In Chapter Two, an integrated review of the literature on patients’ attitudes and perceptions related to the collection of information about sexual orientation and gender identity in the healthcare setting is reported. In Chapter Three, a qualitative study to determine nurses’ experiences, attitudes, and perceptions related to collecting information about sexual orientation and gender identity in the home healthcare setting is reported, and emergent barriers and facilitators discussed. In Chapter Four, a data mining study to examine what is documented about sexual orientation and gender identity in narrative home care nurses’ notes in an electronic health record is described. Finally, in Chapter Five, the findings of the three studies are summarized, overarching conclusions reported and implications for policy, practice and research are discussed.

The U.S. health care system of the 21st century is in desperate need of reform. Patients are being harmed in the hundreds of thousands attributable to medical errors, identified as the third leading cause of death in hospitals. The need for health care reform is further validated by the trillions of dollars that are infused into the U.S. health care system, where quality of care benchmarks are among the worst in the world. The historical evolution of the U.S. health care system was predicated on nurses who served as advocates and innovators of safe workplace and patient care practices. The Code of Ethics and Nurse Practice Act(s) for registered nurses and the requirements of registered nurse licensure in the 21st century, partnered with an ethical barometer in the delivery of quality patient care, command that registered nurses maintain their historical role as advocates and innovators to promote and maintain safe workplace and patient care practices. Registered nurses in the 21st century are being stifled in the fulfillment of what is commanded of them professionally. It is the quagmire of fulfilling their advocate, innovator role and being penalized with unjust discipline shortly thereafter that is stifling. This “coincidence” is silencing registered nurses across the United States. The aim of this study was to employ a hermeneutic phenomenological research design utilizing Max van Manen’s phenomenology of practice to explore the lived experience of unjust discipline among registered nurses. Audio-recorded interviews were conducted with the participants of the study. Vivid descriptions of the participants’ lived experiences of unjust discipline were communicated. Transcripts were generated from the audio recordings. An interpretive analysis utilizing the hermeneutic circle disclosed nine essential themes among the participants’ experiences of unjust discipline. Respondent feedback augmented validity in the interpretive processes during data collection and thematic analysis. In the context of the study, it was evident that unjust discipline is a disruptive workplace behavior that potentiated physical workplace violence. Further, authentic social support may have precluded many of the elements of unjust discipline experienced by the participants during the lived experience of unjust discipline.