Early diagnosis is a promising strategy to reduce premature mortalities and for optimal use of resources. But the absence of mathematical models specific to the data settings in LMIC’s impedes the construction of economic analysis necessary for decision-makers in the development of cancer control programs. This thesis presents a new methodology for parameterizing the natural history model of breast cancer based on data availabilities in low and middle income countries, and formulation of a control optimization problem to find the optimal screening schedule for mammography screening, solved using dynamic programming. As harms and benefits are known to increase with the increase in the number of lifetime screens, the trade-off was modeled by formulating the immediate reward as a function of false positives and life-years saved. The method presented in thesis will provide optimal screening schedules for multiple scenarios of Willingness to Pay (numeric value assigned for each life-year lived), including the resulting total number of lifetime screens per person, which can help decision-makers evaluate current resource availabilities or plan future resource needs for implementation.

Nonvocal alert patients in the intensive care unit setting often struggle to communicate due to inaccessible or unavailable tools for augmentative and alternative communication. A novel communication tool, the Manually-Operated Communication System (MOCS), was developed for use in intensive care settings for patients unable to speak due to mechanical ventilation. It is a speech-generating device designed for patients whose limited manual dexterity precludes legible writing. In a single-arm device feasibility trial, 14 participants (11 with tracheostomies, 2 with endotracheal tubes, and 1 recently extubated) used MOCS. Participants, family members, and observing nurses were interviewed whenever possible. Interviews included a modified version of the System Usability Scale (SUS) as well as open-ended questions; a qualitative immersion/crystallization approach was used to evaluate these responses. Participants with a tracheostomy and their family members/care providers rated MOCS on the SUS questions as consistently “excellent” (average rating across all groups was 84 +/- 17; all subgroups also rated the device highly). Through a qualitative interview process, these stakeholders expressed support for the use of MOCS in the ICU. Based on these data, MOCS has the potential to improve communication for nonvocal patients with limited manual dexterity.

It has been shown that the use of Health Information Technology (HIT) is associated with reduced cost and increased quality of care. This dissertation examined the use of registries in Patient Centered Medical Home (PCMH) practices. A survey questionnaire was sent to a nationwide group of clinics certified for being a PCMH. They were asked to provide information about their payer mix, implementation barriers, registry implementation, registry use, and clinic satisfaction. The survey instrument was validated by an expert panel which included practitioners and researchers. Statistical methods including Structural Equation Modeling were used for analysis and to test the research hypotheses. The majority of medical home practices that responded used some type of computerized registry, either with basic patient information or integrated with detailed clinical information. And on average, they somewhat used registries for population management, individual health management, proactive care and planned care visits. All practices encountered some combination of barriers when implementing a medical home program. Most practices reported clinic satisfaction at least improved after becoming a medical home. The results of the analysis show that indeed payer mix, in particular Medicare and private insurance, has a significant relationship with level of registry implementation. There were no significant relationships between barriers and registry implementation or use. More sophisticated registry implementation led to greater registry use. And registry use is associated with increased clinic satisfaction. This research fills an important gap in understanding Health IT use, registries in particular, among Patient-Centered Medical Homes. The findings suggest that: 1) Implementation barriers may not be influencing use of computerized registries in medical home practices; 2) Using more sophisticated computerized registries facilitates registry use, which can help improve clinic satisfaction; 3) Payer mix may influence use of more sophisticated Health IT in medical home practices.

Indiana University-Purdue University Indianapolis (IUPUI) / Living donors have contributed about 6,000 kidneys per year in the past 10 years, but more than 100,000 individuals are still waiting for a kidney transplant. Living kidney donors undergo a major surgical procedure without direct medical benefit to themselves, but comprehensive follow-up information on living donors’ health is unfortunately limited. Expert recommendations suggest capturing clinical information beyond traditional sources to improve surveillance of co-morbid conditions from living kidney donors. Currently the United Network for Organ Sharing is responsible for collecting and reporting follow-up data for all living donors from U.S. transplant centers. Under policy implemented in February of 2013, transplant centers must submit follow-up date for two years after donation, but current processes often yield to incomplete and untimely reporting. This dissertation uses a statewide Health Information Exchange as a new clinical data source to 1) retrospectively identify a cohort of living kidney donors, 2) understand their follow-up care patterns, and 3) observe selected clinical outcomes including hypertension, diabetes and post-donation renal function.

As the public and government officials become aware of the impact of public health on communities, it is important that relevant public health statistics be available for decision making. Existing web resources have limited visualization options, cannot visually compare a county to all others in the US, and cannot compare the counties in an arbitrary region to all others in the US. The College of Public Health Indicator Visualization Tool (CPHIVT) is a web application providing visualization and ranking for a county in the US in comparison to all counties for a specific health indicator. An iterative development methodology was used to complete major features and refine the features over time. Features divided into small tasks that could be completed within two-week cycles. After the first version of the web application was completed and presented to the client, client feedback on the application was used to refine specifications and was incorporated into planning for future iterations. Iterative development was adopted with a focus on improving and expanding existing features and making the application publicly available online. A suite of automated user interface tests is being developed to verify the application’s functions. Making a complete version of the application publicly available involves significant research and software configuration to deploy the web application in a secure and performant manner. The web application has two major components corresponding to its two major user groups. The first component allows authenticated users from the Department of Public Health to upload and manage sets of data for various health indicators. Tools are included to automatically process uploaded data points. This allows the information presented on the web site to be expanded and kept up to date over time with minimal effort. The second component is accessible to anyone and allows a user to choose to a state or county with text search or hierarchical navigation. The application then provides graphical charts showing that location’s standing for various health indicators compared to all other counties nationally. This is accomplished by applying percentile rankings to the counties and plotting the percentiles against the values for a selected indicator. A user can save a generated chart to a variety of export formats including PNG image or PDF document. The application is expected to serve as a tool for many community members. Staff and students at the College of Public Health will use this tool for presentations and research. County health departments will be able to use the tool when planning community programs. County government leaders can use this tool to determine areas of need in the community. Decision makers will have the ability to visualize their county or region as compared to the nation, not just to neighboring counties or within a state.

Quality chest compressions during Cardiopulmonary Resuscitation (CPR) are vital to maintaining adequate perfusion of oxygenated blood to the organs of the body to sustain life. Over the years, the compression rate recommended in Basic Life Support (BLS)/ Advanced Cardiac Life Support (ACLS) protocols for the best possible outcome has risen, and with that increase there are questions regarding rescuer fatigue and the effectiveness of compressions. Layperson and professional rescuers, answering to an emergency, both maintain continuous chest compressions until advanced life support arrives. Depending on the location, this arrival time would most likely be longer than the two minute standard time given to rotate rescuers before fatigue compromises performance. The objective of this research was to investigate the level of rescuer fatigue associated with continuous compressions, varying compression rates, physical fitness, gender, and among layperson versus professional rescuers. Sixty-one participants performed uninterrupted chest compressions on a manikin for 15 minutes. Before performing compressions, physical fitness was evaluated using a YMCA bench press for an assessment of upper body strength/endurance and a 3-minute step test to evaluate aerobic fitness. Subjects performed two trials at compression rates of greater or equal to 80 and greater or equal to 100 per minute with a 5-minute rest between trials. Male professional rescuers had a greater strength/endurance, and thus were able to perform compressions for a longer period of time compared to their female counterparts. Compression duration and the YMCA Bench Press test score were significantly correlated (p = .0135). Cardiocerebral Resuscitation providers should maintain an adequate upper body strength, particularly if they may be required to perform continuous chest compressions at high rates for more than a few minutes.

Indiana University-Purdue University Indianapolis (IUPUI) / Health Information Technology (HIT) has become an integral component of healthcare today. The HITECH Act (2009) and Meaningful Use objectives stand to bring wide-sweeping adoption and implementations of HIT in small, medium and large sized healthcare organizations across the country. Though recent literature has provided evidence for the benefits of HIT in the profession, there have also been a growing number of reports exploring the adverse effects of HIT. There has not, however, yet been a systematic account of the adverse effects of HIT in the healthcare system. The current push for HIT coupled with a lack of critical appraisal of the potential risks of implementation and deployment within the medical literature has led to a general unquestioning and unregulated acceptance of the implementation of technology in medicine and healthcare as a positive addition with little or no risk. While the benefits of HIT are clear, a review of the existing studies in the literature would provide a holistic vision of the adverse effects of HIT as well as the types and impact within the nation’s health care system to inform future HIT development and implementation. The development of a general understanding of these adverse effects can serve as a review and summary for the use of informatics professionals and clinicians implementing HIT as well as providing future direction for the industry in HIT implementations. Additionally, this study has value for moving forward in informatics to develop frameworks for implementation and guidelines and standards for development and regulation of HIT at a federal level. This study involves the use of an integrative literature review to identify and classify the adverse effects of HIT as reported in the literature. The purpose of this study is to perform an integrative review of the literature to 1) identify and classify the adverse effects of HIT; 2) determine the impact and prevalence of these effects; 3) identify the recommended actions and best practices to address the negative effects of HIT. This study analyzed 18 articles for HIT-induced error and adverse consequences. In the process, 228 errors and/or adverse consequences were identified, classified and represented in an operational taxonomic schema. The taxonomic representation consisted of 8 master categories and 30 subcategories. Additionally, the prevalence and impact of these errors were evaluated as well as recommendations and best practices in future systems design. This study builds on previous work in the medical literature pertaining to HIT-induced errors and adverse consequences and offers a unique perspective in analyzing existing studies in the literature using the integrative review model of research. It is the first work in combining studies across healthcare technologies and analyzing the adverse consequences across 18 studies to form a cohesive classification of these events in healthcare technology.

As the bulk of medical health records shift from paper-based file systems to electronic formats, the promise of the transformation process called healthcare reform included adding efficiencies to medical practice workflows, lower costs, improved quality of care and most important, and the freeing of patient information from traditional propriety silos. With this incoming largess of protected health information data now viewable through online patient portals, patients can be empowered to become educated and active in their own health care decisions, but only if they have admission to their information. A digital divide currently exists in many medical practices where only a very few patients have access to their personal health information. The primary goal was to facilitate organizational change needed for physician-managed practices to increase patient adoption and meaningful use of patient portals for secure communication, wellness education, review of labs and other tests, and receipt of clinical summaries. The methodology utilized the appreciative inquiry 4-D model as the underlying basis of three phases: Phase 1-fundamental study, Phase 2-strategic action plan, and Phase 3 supporting organizational change. The physicians or providers in independent medical practices are the key determinate of the organizational workflows. The results have added significantly to the understanding of organizational change as related to patient engagement and the adoption and meaningful use of patient portals in independent physician-managed clinics. As medical practices and their physician leaders raise patient portal workflow processes to a higher level of importance, it is expected that patients will begin to adopt these procedures as their preferred methods and bring about a change in the patient-provider relationship.

Consumers have begun to take a more proactive approach to their healthcare by accessing pharmaceutical companies Websites to obtain health and drug information, support groups, rebates, coupons, as well as free drug trials. In exchange for these benefits, companies require consumers to voluntarily disclose information. However, research has shown that consumers continue to be concerned about how their information is managed, used, and distributed by companies, especially if accessed via the Web. To date, there has been limited empirical research to examine the actual online practices of companies when it comes to privacy, especially those of pharmaceutical companies. Using Delphi expert panel process, the components of a benchmarking index were identified to examine the documented and actual online practices of 100 Website registrations with pharmaceutical companies. The evolution for the development of an index to measure the personal information privacy violations of pharmaceutical companies is presented. Second, empirical evidence is provided regarding the magnitude of voluntary adherence to the Fair Information Practices (FIPs) by pharmaceutical companies based upon the personal information privacy violations. The results revealed that companies with headquarters in Europe had fewer personal information privacy violations than those in Asia, UK, and the US. Moreover, the results indicate that fewer personal information privacy violations occur for chronic conditions than for non-chronic conditions, as well as fewer violations occur with Website registrations for updates than for discounts. Finally, both Europe and UK demonstrated more overall adherence to FIPs than the US and Asia. This suggests that self-regulation may not be sufficient, while more enforcement may be necessary to decrease personal information privacy violations.

Adverse Childhood Experiences (ACEs) include childhood exposure to abuse or violence, a parents' divorce, mental illness, substance use disorder, and are identified as risk factors for negative life outcomes. While ACEs screenings are commonly used in mental health and pediatric settings, screening for ACEs in primary care settings is less prevalent. The purpose of this project is to integrate screening for ACEs into a primary care setting and make appropriate referrals for follow-up, thus reducing potential negative life outcomes. The process was designed for a primary care practice located in Winston-Salem, North Carolina. Part one assessed level of awareness and screening history which determined training focus. Each provider and staff member received 30-45 minutes of training on ACEs screening algorithm, a detailed approach to guide treatment. The training was followed by question-and-answer sessions to address concerns. Part two, involved screening using the Center for Youth Wellness, Adverse Childhood Experiences Questionnaire for Children (CYW ACE-Q Child) which was initiated by the front office employee. Front office employee identified patients present for an annual well visit, briefly explained the screening tool, and handed it to the patient on a clipboard. The patient returned the completed form to the Certified Medical Assistant (CMA) when called in from the waiting room. The provider reviewed the ACEs screening and made referrals as appropriate. Part three involved data collection and analysis. Responses were collected weekly for nine weeks. The responses collected will be analyzed using quantitative statistics. The expected outcome is to note progressive increase in screening activities and when appropriate, followed by referrals to community agencies and organizations. The project educated clinicians about ACEs and created awareness among clinicians in a primary care setting to mitigate potential negative life outcomes. Barriers to integrating ACEs screening included employees' absence of training, lack of confidence in the subject matter, limited time frame to complete the screening, and fear of damaging patient-provider relationships. Barriers were mitigated through employee training, repetitive implementation of ACEs screening, and therapeutic communication with patients. The CYW ACE-Q was reserved for those arriving early or on time for their annual wellness visit to allow adequate time for completion. Recommendations include incorporating the CYW ACE-Q into all primary care visits to further intervene with referrals thereby enhancing patients' overall quality of life.