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

Community Health Centers (CHCs) are the nation's primary care safety-net for vulnerable populations, including racial/ethnic minorities, migrant workers and the uninsured. Women from these populations contribute disproportionately to cervical cancer morbidity and mortality, largely due to underutilization of Pap smear screening. The purpose of this cross-sectional study was to identify factors that may be related to Pap smear screening compliance among a large cohort of women seen at 10 Community Health Centers in Florida. Building upon an ecologic framework, this research went beyond patient-level risk factors, which are generally well-known, and explored provider and organizational variables that may also be associated with Pap smear screening compliance in this population. Ten CHCs in Florida met study inclusion criteria of having at least four complete years of claims and patient registration data stored in an Electronic Health Record (HER) data system maintained at HCN. EHR data were merged with provider gender obtained from a credentialing database and with data from a short organizational survey administered to the Medical Directors of the CHCs. Descriptive statistics, chi-squared analysis, and multiple logistic regression were used to examine Pap smear screening rates for women (n=71,234) in relation to a variety of patient, provider and organizational variables. Younger, Hispanic and insured women were most likely to have had a screening in the past three years compared to older, white non- Hispanic and uninsured women. Among providers, patients who received care from female providers generally had higher Pap smear compliance rates, but these findings differed by patient insurance and race/ethnicity group. Organizational factors that appeared to be associated with higher Pap compliance rates included diffusion of an EHR system, implementation of "Care Model Principals", and having recently implemented a Pap smear screening process improvement project. Results demonstrated that multi-level factors, operating on the patient, provider and organizational levels, contribute to Pap smear compliance among women seen at CHCs. Results suggested that improving screening compliance within this population of women requires interventions that are ecologic in scope, incorporate targeted education to high-risk women and providers, and include organizational strategies that can optimize care delivery at point-of-care.

<p>This dissertation aimed to investigate the use of electronic nursing documentation as a strategy to improve the quality of care provided to hospitalized patients. The literature to support the use of electronic nursing documentation on the quality of care delivered to patients is limited to date. Additionally, the literature describing the use of information for the delivery of care on paper-based nursing documentation is limited. This dissertation reviews the current literature, investigated the knowledge needed for nurses to know their patients and established categories of nurses' information needs as preliminary work to be able to descriptively compare the use of paper with electronic nursing documentation on inpatient care units within a hospital setting. The main study conducted for this investigation used a mixed-methods multiple case study design, to describe the processes of information use on two inpatient care units, while first using paper and subsequently electronic nursing documentation. Findings revealed the importance of the categories of nurses' information needs for both cases in addition to the use of verbal, paper-based and electronic information sources for the collection, communication and temporary storage of information needs. Additionally, the conversion to electronic nursing documentation introduced new challenges related to three quality metrics: efficiency, timeliness and safety. Recommendations are provided for further evaluation of electronic health records with additional consideration for appropriate hardware devices in the context of the care environment.</p> / Dissertation

In health services, it is a necessity to keep the records of the patients. Although paper-based records are commonly used for this aim, they are not as convenient as computerized records. Therefore, many of the health facilities have recently started keeping patients&rsquo / health records in electronic databases. However, new questions about confidentiality and privacy of these records were raised with this new system.This study aims to investigate the opinions and attitudes of the people who use the health services of Turkey about the privacy and confidentiality of health information in electronic environment. In the survey, there are 596 participants from 64 different cities in six geographical regions of Turkey. The findings show that people feel comfortable about computer usage in health-care but they are concerned about the privacy and confidentiality of their information and also they are not sure if their medical information is safe and secure now. Moreover, they are mostly unaware about current regulations related to information privacy in Turkey. The study also shows that people trust in their doctors, health researchers in universities, pharmacist, nurses and other hospital staff but do not trust in insurance companies, government, private sector health researchers, information technology specialists and government health researchers for the privacy of their medical records.

The implementation of planned organizational change is ultimately a communication-related phenomenon, and as such, it is imperative that organizational communication scholars examine the interactions surrounding EHR implementation and understand how users (e.g. healthcare practitioners) utilize, evaluate, and deliberate this new technological innovation. Previous research on planned organizational change has called for researchers to adopt a more dynamic perspective that emphasizes the active agency of organizational members throughout implementation processes and focuses on informal implementers and change reinvention (work-arounds) as individuals actively reinterpret and personalize their work roles during implementation socialization. This dissertation seeks to fill this gap in research by demonstrating how communication between doctors, nurses, and other health professionals affects the adoption, maintenance, alternation, modification, or rejection of EHR systems within health care organizations. To delve into these inquiries and examine the intersecting domains of medical informatics and organizational communication research, this dissertation proceeds in the following manner: First, a literature review, capitalizing on Laurie Lewis’s work in planned organizational change and social constructionist views of technology use in organizations, outlines the assumptions that undergird this research. Next, this dissertation builds a model that predicts the communicative and structural antecedents of the study outcome variables, which include 1) organizational resistance to EHR implementation, 2) employees’ perception of EHR implementation success, 3) levels of change reinvention—or work-arounds—due to change initiatives and activities, and 4) employees’ perceptions of the quality of the organizational communication surrounding the change. Hypotheses guiding the model specification are provided and are followed by a description of the empirical methods and procedures that were utilized to explore the variable relationships. Results of the SEM model suggest that work-arounds could play a mediating role governing the relationship between informal social influence and the outcome variables in the study. In addition, one-way ANOVAs and multiple regression analyses reveal that physicians are the most resistant to EHR implementation and perceived change communication quality positively predicts perceived EHR implementation success and perceived relative advantage of EHR and negatively predicts employee resistance. A discussion of the expected and unexpected results is offered in addition to study limitation and future directions. / text

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A rise in chronic conditions has put a strain on our healthcare system. Treatment for chronic conditions spans time, agencies, and providers, making coordination a complex problem. Information systems such as electronic health records should be helping with the challenge of coordination, but research shows that often they do not. This thesis aims to alleviate this problem by examining the design of health information technology with an emphasis on social and organizational processes. The focus of this thesis is on the implications of continuous care over time: the shift from a single provider to team-based services, the emergence of patients and families as primary caregivers in the home, and the diffusion of data-driven decision making. I investigated these trends to understand the role of data in coordinating long-term care, and inform the design of information systems. I studied behavioral and mental health services for children, which are coordinated across clinical, home, and special education settings. I found coordination that was unstructured, unpredictable, and adaptive. I developed a conceptual framework, collaborative reflection, to describe my observations and distinguish my findings from the processes of time-critical and protocol-based care. I also found ways in which coordination was not data-driven, due to a lack of support and tools. Collaborative reflection thus illustrates how long-term coordination works when it is data-driven, informing a discussion of what is needed for coordination to be data-driven. Based on the process of collaborative reflection, and using participatory design, I developed Lilypad—a tablet-based information system for data-driven coordination. I conducted a five-month deployment study of Lilypad in the field, to examine its social impact. This study validated designing for collaborative reflection to improve the use of data in coordination. The contributions of this thesis are: a description of unstructured and informal workflow that drives long-term coordination in health services; the theoretical construct of collaborative reflection to inform the design of systems that improve coordination; a field deployment validation, demonstrating how designing for collaborative reflection improves coordination and avoids common unintended consequences of health information technology.

The implementation of Electronic Medical Records (EMRs) may lead to improved quality of primary health care. To investigate this, we conducted a mixed methods study of eighteen Toronto family physicians who implemented EMRs in 2006 and nine comparison family physicians who continued to use paper records. We used a controlled before-after design and two focus groups. We examined five preventive services with Pay for Performance incentives: Pap smears, screening mammograms, fecal occult blood testing, influenza vaccinations and childhood vaccinations. There was no difference between the two groups: after adjustment, combined preventive services for the EMR group increased by 0.7% less than for the non-EMR group (p=0.55, 95% CI -2.8, 3.9). Physicians felt that EMR implementation was challenging.

The implementation of Electronic Medical Records (EMRs) may lead to improved quality of primary health care. To investigate this, we conducted a mixed methods study of eighteen Toronto family physicians who implemented EMRs in 2006 and nine comparison family physicians who continued to use paper records. We used a controlled before-after design and two focus groups. We examined five preventive services with Pay for Performance incentives: Pap smears, screening mammograms, fecal occult blood testing, influenza vaccinations and childhood vaccinations. There was no difference between the two groups: after adjustment, combined preventive services for the EMR group increased by 0.7% less than for the non-EMR group (p=0.55, 95% CI -2.8, 3.9). Physicians felt that EMR implementation was challenging.

The purpose of this research was to determine if patient journey process modeling could act as a change management tool to support electronic health record (EHR) adoption, at a tertiary-care mental health centre. This research study was based on a pre/post design, which evaluated the attitudes of clinicians??? pre and post implementation of the EHR. A survey was used to assess the attitudes of various healthcare professionals, such as physicians, nurses and a spectrum of allied health disciplines, at various phases of the planning and implementation process. In addition to the surveys, current and future state PaJMa (patient journey modeling architecture) models representing technology use and process flows of all units were created by observational studies, and served as change management tools. These PaJMa models were then presented as part of an intervention that was held in the form of an educational session to highlight the benefits of technology, and to address the common concerns identified from the initial survey results. The centre for mental health sciences facility was used as the case study to apply the PaJMa model and assess its change management functionality. Since, the organization was moving from paper to electronic based patient charts it was an ideal choice for this research. It was predicted that the attitudes and opinions of clinicians towards the EHR implementation, and EHRs in general, would change and become more positive with increased knowledge and education. This in-turn would increase EHR adoption and hence lead to a successful implementation.