<p>Canadian primary care practices lag behind their counterparts in the United States and Europe in adopting Electronic Medical Record (EMR) systems to facilitate care. Although there is a considerable volume of cross-national conceptual literature focused on system design and barriers to adoption, there is little in the way of research on the unique problems faced by Canadian physicians within the publicly financed and privately provided system of healthcare delivery. This study uses a survey of Canadian physicians to investigate differences in perceptions of EMR value between two groups who have implemented these systems: “small practice” physicians, i.e. those with a maximum of 2 full-time physicians and “large practice” physicians, or those with three or more full-time physicians. A Mann-Whitney U Test conducted on survey item responses of the two groups finds that “small practice” physicians feel significantly less positive about EMRs with regards to ease of use, time savings and effective patient management.</p> / Master of Science (MSc)

<p>Chronic low back pain is the second most prevalent chronic condition in Canadian primary care settings. The treatment and diagnosis of chronic pain is challenging for primary care clinicians. Their main challenges are lack of knowledge and their approach toward assessing and treating pain. Evidence based guidelines have been developed for neuropathic pain and low back pain.</p> <p>CDSSs for chronic diseases are becoming popular in primary care settings as a mean to implement CPGs. A CDSS prototype for diagnosis and treatment of chronic, non-cancer pain in primary care was developed at McMaster University. It is evident that poor usability can hinder the uptake of health information technologies.</p> <p>The objective of this study was to test the usability of Pain Assistant using think aloud protocols with SUS scores in 2 iterations. In this study 13 primary care providers including family physicians, nurse practitioners and residents used Pain Assistant to complete 3 different patient case scenarios. Participants were asked to comment on both barriers and facilitators of usability of Pain Assistant. Additionally time to complete patient case scenarios was calculated for each participant. A comparison questionnaire gathered user preference between introducing CPGs in paper format and computerized decision support system.</p> <p>This study showed that iterative usability testing of the Pain Assistant with participation of real-end users has the potential to uncover usability issues of the Pain Assistant. Problems of user interface were the main usability barrier in first testing iteration following by problems of content. Changes were made to system design for second round based on the issues came up in the first iteration. However, because of time constrains not all the changes were implemented for second round of testing. Most of the refinements were to resolve user interface issues. In the second iteration, the problems with the content of Pain Assistant were the major barrier. The changes to the system design were successful in resolving user interface problems since the changed issues did not come up again in second round. Pain Assistant had an above the average usability score however no significant changes seen in SUS score. The time needed to complete tasks remained identical in both iterations. In addition, participants preferred to have CPGs in electronic formats than paper. Further study after implementing all the system changes needed to determine the effectiveness of system refinements.</p> / Master of Science (MSc)

Implant terms are terms like "pacemaker" which indicate the presence of artifacts in the body of a human. These implant terms are key to determining if a patient can safely undergo Magnetic Resonance Imaging (MRI). However, to identify these terms in medical records is time-consuming, laborious and expensive, but necessary for taking the correct precautions before an MRI scan. Automating this process is of great interest to radiologists as it ideally saves time, prevents mistakes and as a result saves lives. The electronic medical records (EMR) contain the documented medical history of a patient, including any implants or objects that an individual would have inside their body. Information about such objects and implants are of great interest when determining if and how a patient can be scanned using MRI. This information is unfortunately not easily extracted through automatic means. Due to their sparse presence and the unusual structure of medical records compared to most written text, makes it very difficult to automate using simple means. By leveraging the recent advancements in Artificial Intelligence (AI), this thesis explores the ability to identify and extract such terms automatically in Swedish EMRs. For the task of identifying implant terms in medical records a generally trained Swedish Bidirectional Encoder Representations from Transformers (BERT) model is used, which is then fine-tuned on Swedish medical records. Using this model a variety of approaches are explored two of which will be covered in this thesis. Using this model a variety of approaches are explored, namely BERT-KDTree, BERT-BallTree, Cosine Brute Force and unsupervised NER. The results show that BERT-KDTree and BERT-BallTree are the most rewarding methods. Results from both methods have been evaluated by domain experts and appear promising for such an early stage, given the difficulty of the task. The evaluation of BERT-BallTree shows that multiple methods of extraction may be preferable as they provide different but still useful terms. Cosine brute force is deemed to be an unrealistic approach due to computational and memory requirements. The NER approach was deemed too impractical and laborious to justify for this study, yet is potentially useful if not more suitable given a different set of conditions and goals. While there is much to be explored and improved, these experiments are a clear indication that automatic identification of implant terms is possible, as a large number of implant terms were successfully discovered using automated means.

Indiana University-Purdue University Indianapolis (IUPUI) / Identifying spatial and temporal patterns of disease occurrence by mapping the residential locations of affected people can provide information that informs response by public health practitioners and improves understanding in epidemiological research. A common method of locating patients at the individual level is geocoding residential addresses stored in electronic medical records (EMRs) using address matching procedures in a geographic information system (GIS). While the process of geocoding is becoming more common in public health studies, few researchers take the time to examine the effects of using different address databases on match rate and positional accuracy of the geocoded results. This research examined and compared accuracy and match rate resulting from four commonly-used geocoding databases applied to sample of 59,341 subjects residing in and around Marion County/ Indianapolis, IN. The results are intended to inform researchers on the benefits and downsides to their selection of a database to geocode patient addresses in EMRs.

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

Opportunistic infections (OIs) have been identified as a leading cause of poor outcomes in the ARV therapy (ART) programme. In order to reduce OIs, the Malawi, MoH introduced routine prescription of cotrimoxazole preventive therapy (CPT) in 2005. The MoH also started scaling up a point-of-care electronic medical record (EMR) system in 2007 to improve monitoring and evaluation. This study had the following objectives: i) to quantify prescription of CPT before and after implementing EMR; ii) to compare the difference in CPT prescription before and after implementing EMR. A historically controlled study design was used to compare CPT prescriptions one year before, and one year after implementation of the EMR at two health facilities. The data indicated that there was a significant (P <0.001) decrease in CPT prescribing at one health facility and a significant increase in CPT prescription at another. / Health Studies / M.A. (Public Health)

The purpose of this study is to investigate the right to confidentiality in the context of HIV/AIDS through an interdisciplinary lens. This study indicates that whilst confidentiality is important and should be preserved in order to protect persons living with HIV/AIDS against stigmatisation, discrimination and victimisation, this should be balanced by other equally important interests, such as the protection of public health and individual third parties who may be affected by the intentional or negligent infection of others with HIV. As the consideration of the legal issues relating to confidentiality and privacy cannot be divorced from the social context in which HIV/AIDS plays out in South African communities, the study will examine, amongst others, the victimisation, discrimination and stigmatisation experienced by persons living with HIV/AIDS, followed by a critical exploration of the present legal and ethical framework governing privacy and confidentiality, including medical confidentiality, as well as the duty to disclose a positive HIV-status, in the context of HIV/AIDS. Possible limitations on the right to privacy in this context are also examined, which include, amongst others, a consideration of making HIV/AIDS notifiable diseases in South Africa. The study suggests that it is imperative that legal interventions aimed at curbing the spread of HIV will need to be mindful of the unique social, cultural and economic forces that impact on the duty to disclose a positive HIV-status to partners and other affected third parties. Insights gained from philosophical theories relating to Africanism, individualism, communitarianism and utilitarianism are valuable tools in facilitating a clearer understanding of relevant social and cultural factors that keep South African society locked in the present stalemate with regard to the disclosure of HIV status. / Public, Constitutional, & International law / LLD

Ce travail aborde les développements de la psychiatrie dans les colonies italiennes de la Corne de l’Afrique et de la Libye. La psychiatrie coloniale – que l’on appelle aussi ‘ethnographique’, ‘comparée’, ‘raciale’ – se nourrit de théories anthropologiques consolidées, de mensurations anthropométriques, d’observations cliniques ; c’est dans ce cadre complexe qu’elle émerge comme discipline autonome, en partie au moins, par rapport à la psychiatrie de le mère-patrie et qu’elle contribue au bon fonctionnement du régime colonial. Les protagonistes sont en premier lieu les médecins et les patients ; à l’arrière plan on trouve aussi les administrateurs et les hommes politiques, ou encore les familles et les communautés d’origine des patients. À travers des documents précieux comme les dossiers médicaux, il est possible de reconstituer les parcours des patients, de raconter des histoires de vie et d’identifier des éléments récurrents dans les différentes expériences. De plus, grâce à la documentation privée de certains médecins coloniaux, il est possible de saisir les motivations qui poussaient certains spécialistes à venir exercer dans les colonies. L’étude de la littérature psychiatrique de l’époque, associée à l’analyse des parcours des médecins, fait apparaître les échanges et les influences qui marquaient l’activité des psychiatres coloniaux. En ce sens il m’a semblé important d’analyser les modèles anglais et français dont les médecins italiens déclarent s’inspirer dans leur réflexion théorique et donc dans la construction de la discipline ainsi que dans les solutions pratiques mises en œuvre pour faire face à la question psychiatrique dès le début des différentes expériences coloniales. Le nœud de l’assistance aux colons et aux militaires qui présentaient des troubles psychiques, ainsi qu’aux indigènes considérés fous, a plus retenu l’attention dans la colonie libyenne (déjà en 1911-1912, avec des réalisations institutionnelles dans les années trente) tandis que dans les colonies de l’Afrique orientale italienne, la question de l’assistance psychiatrique a été moins débattue, débouchant par conséquent sur très peu de réalisations pratiques. / The dissertation reviews the ways in which psychiatry developed in the Italian colonies in the Horn of Africa and in Libya. Colonial psychiatry – variously called “ethnographic”, “comparative”, or “racial” psychiatry – drew on established anthropological theories, anthropometric measurements and clinical observations, the consistently-organized framework within which it emerged as an discipline supporting colonial government and at least partially independent of psychiatry in the home country. The primary interaction within this colonial psychiatry was that between doctors and patients; in the background were the colonial administrators, the political decision-makers, and the patients’ families and home communities. Precious documentary resources such as medical records let us trace patients’ careers, tell their life stories, reconstruct typical cases and confirm recurrent features in their various experiences; from the private papers of some colonial doctors we can gather the specialists’ motivations to move to the colonies; and an examination of the psychiatric literature of the day enables us to reconstruct the discussions and inspirations which fostered the work of the colonial psychiatrists. I have recognized the importance of analysing the British and (still more) the French models from which the Italian clinicians claimed to draw their inspiration, both in terms of theory (and the construction of the resulting discipline), and in the practical solutions implemented to tackle psychiatric issues from the earliest days of the various colonial experiments. This issue – of supporting psychiatrically-afflicted colonists and soldiers and natives regarded as “mad” – was paid most attention in the Libyan colony, starting in the very first months of the occupation (in 1911 and 1912) and then taking institutional form in the 1930s; in the colonies of what was known as “Italian East Africa”, on the other hand, there was less discussion of psychiatric support and correspondingly limited practical achievements. / La tesi percorre gli sviluppi della psichiatria nelle colonia libica e nelle colonie del Corno d’Africa. La psichiatria coloniale – che assume denominazioni diverse: ‘etnografica’, ‘comparata’, ‘razziale’ – si nutre di teorie antropologiche consolidate, di misurazioni antropometriche, di osservazioni cliniche ed è in questo quadro articolato che emerge come disciplina autonoma, almeno in parte, rispetto alla psichiatria della madrepatria, e funzionale al buon ordine del regime coloniale. Nella cornice della psichiatria coloniale interagiscono in primo luogo medici e pazienti; sullo sfondo ci sono gli amministratori e i decisori politici, le famiglie e le comunità di provenienza dei pazienti. Attraverso documenti preziosi come le cartelle cliniche è possibile tracciare le traiettorie dei pazienti, raccontare storie di vita, ricostruire casi esemplari e fissare dei punti ricorrenti nelle diverse esperienze. Grazie alla documentazione privata di alcuni medici coloniali è possibile cogliere le ragioni che spingevano gli specialisti in colonia. Infine la letteratura psichiatrica del periodo preso in esame permette di ricostruire gli scambi e le ispirazioni che alimentavano l’attività degli psichiatri coloniali. In tal senso si è ritenuto importante analizzare i modelli inglese e soprattutto francese a cui i medici italiani dichiarano di ispirarsi, sia nella riflessione teorica e quindi nella costruzione della disciplina, sia nelle soluzioni pratiche attuate per far fronte alla questione psichiatrica sin dai primi tempi delle diverse esperienze coloniali. Tale questione, ovvero il problema dell'assistenza ai coloni e ai militari che presentavano disturbi psichiatrici nonché agli indigeni ritenuti folli, ha ricevuto maggiore attenzione nella colonia libica, e questo sin dai primi mesi della sua occupazione, tra 1911 e 1912, per poi manifestarsi in realizzazioni istituzionali negli anni Trenta; mentre nelle colonie della cosiddetta Africa Orientale Italiana il tema dell’assistenza psichiatrica è stato meno dibattuto, sfociando pertanto in scarse realizzazioni pratiche.

Es wurde eine Datenbankmanagementsystem-Anwendung zur Dokumentation von Patienten mit Lippen-Kiefer-Gaumenspalten entwickelt. Ziel des Computerprogramms ist, anhand großer Patientenzahlen weitere statistisch abgesicherte Daten zur Heredität, anderen ätiologischen Faktoren, Epidemiologie und Therapiebewertung zu gewinnen. Besonderes Augenmerk wurde auf Angaben zu möglichen ursächlichen Faktoren der Spaltentstehung gelegt. Möglicherweise ergeben sich doch einmal durchgreifende präventive Maßnahmen bei Risikoschwangerschaften. Die Auswertung großer Patientenkollektive (seit 1948 etwa 3000 Spaltpatienten an der Charité) im objektiven Vergleich mit anderen Behandlungszentren kann zur Therapieoptimierung beitragen. Zur Analyse werden die funktionellen und aesthetischen Behandlungsresultate in Abhängigkeit vom Therapieverfahren eingeschätzt. Die Gesamtbehandlung erstreckt sich über 20 Jahre. Eine endgültige Ergebnisbeurteilung kann erst nach dieser Zeit erfolgen. Es muß von einer großen Variationsbreite der Behandlungsmodelle ausgegangen werden. Diese müssen an großen Patientenkollektiven statistisch in ihrem Erfolg abgesichert werden. Das Projekt steht im Konsens mit den Empfehlungen des interdisziplinären Arbeitskreises Dokumentation der Arbeitsgemeinschaft Lippen-Kiefer-Gaumenspalten der Deutschen Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie. Die Anwendung wurde auf Basis eines relationalen Datenbankmanagementsystems entwickelt. Das Programm zeichnet sich durch einfache Bedienbarkeit und schnelle Datenerfassung aus. Es ist als detaillierte Erfassung konzipiert. Verschiedenartige Eingabeerleichterungen wurden eingearbeitet. Die Datenerfassung ist weitgehend standardisiert und skaliert. Voraussetzung für diese Eigenschaften, die in ihrer Gesamtheit einen Fortschritt im Vergleich zu vorgenannten anderen Systemen darstellen, war die rasante Entwicklung der Hard- und Softwaretechnik. Nunmehr ist es problemlos möglich, die Datenfülle zu bewältigen. Schon für den einzelnen Patienten besteht durch die vielen beteiligten Fachgebiete, diverse Behandlungsmaßnahmen und wiederholte Kontrolluntersuchungen ein beachtlicher Dokumentationsbedarf. Bei den für die statistische Auswertung nötigen hohen Patientenzahlen resultieren tausende Datensätze. Der erreichte Stand ist nicht endgültig. Das Programm kann ständig weiterentwickelt und angepaßt werden. Bezugnehmend auf andere Systeme soll der interdisziplinäre Charakter noch einmal betont werden. Dafür spricht unter anderem die Netzwerkkompatibilität. Im Wechselspiel mit der Kieferorthopädie, der Hals-Nasen-Ohrenheilkunde, Pädiatrie, Logopädie sowie der konservierenden Zahnheilkunde ergibt sich eine gegenseitige Beeinflussung. Das fand Berücksichtigung bereits im anamnestischen Bereich, setzt sich bei der Diagnose und Befunddokumentation fort. Auch die Menügestaltung ist darauf abgestimmt. Die Wechselwirkung der beteiligten Fachgebiete zu optimieren, ist das Ziel der Auswertung großer Patientenkollektive. Dazu sind ausgezeichnete Voraussetzungen geschaffen worden. Größte Patientenkollektive können nach beliebigen Kriterien und deren Verknüpfung in beeindruckender Schnelligkeit ausgewertet werden. Die Anwendung moderner Erfassungssysteme und insbesondere die Archivierung und Bearbeitung visueller Befunde besitzt nicht nur wissenschaftlichen Wert in ihrer Auswertung oder der Therapieplanung, sondern kann im Praxisbetrieb motivierende Wirkung auf den Patienten haben. Er fühlt sich optimal mit modernsten Mitteln betreut, was die Compliance erhöhen kann. Die eingehende Beschäftigung mit seinen Befunden beziehungsweise mit den Eltern bezüglich der Krankengeschichte vermittelt dem Einzelnen, daß sein Schicksal nicht nur für ihn wichtig ist, sondern sich in die Gesamtheit der Bemühungen einordnet, die Prävention und Therapie der Spaltbildungen zu verbessern. / The efforts in the past to improve the treatment of patients suffering from cleft lip and palate as well as to better understand the etiology of clefts have shown that a large number of cases with very large amount of data will normally have to be assessed considering the natural variation of the cleft lip and palate and the true effects to be apparent clinically and statistically. With the help of computer supported databases it is possible to keep comprehensive records about anamnestic information and results of clinical examination before and after all types of treatment including the assessment of the standard of outcome. If necessary the future treatment approaches can be altered. Therefore a computer supported database system using the latest features of object orientated relational database management systems was developed. The efforts of the German Society Of Maxillofacial Surgery to standardize the clinical records and treatment evaluations were considered. The introduced system features network compatibility, high performance query tools and can be managed by average computer users. Running it on actual customary hardware the processing speed considering the very large amount of data to be collected from thousands of patients with often more than 18 years of treatment is excellent. The introduced system contributes to the general approach to improve the treatment outcome and to better understand the etiology of cleft lip and palate.

O objetivo deste trabalho foi comparar aspectos clínicos de pacientes portadores de fibromialgia cujo início dos sintomas estivessem relacionados a eventos traumáticos e pacientes idiopáticos. Foram avaliados 135 pacientes por meio de um questionário estruturado sobre dados demográficos e situação de produtividade laboral, caracterização da dor e presença de queixas não relacionadas ao aparelho locomotor. Foi realizada contagem e dolorimetria de pressão dos pontos dolorosos e avaliação da dor segundo a escala visual analógica. O grupo de pacientes traumáticos conteve 48 pessoas apresentou maior período médio de escolaridade (8,1 &#177; 4,1 x 5,3 &#177; 2,9; p<0,001), maior contagem de pontos dolorosos (16,1 &#177; 2,8 x 15,0 &#177; 3,2; p = 0,047), menor período desde a generalização da dor (5,6 &#117; 6,9 x 4,1 &#177; 2,6 anos; p = 0,002) e maiores prevalências de dificuldade de concentração (83,0% x 65,1%; p = 0,048) e cólicas intestinais (45,8% x 26,4%; p = 0,036). Houve associação entre o trauma e a improdutividade econômica. Os demais aspetos clínicos não apresentaram diferença estatisticamente significante. Conclui-se que a etiologia traumática impõe poucas diferenças clínicas aos pacientes portadores de fibromialgia e não explicam o grau de incapacidade laboral que se observa. / The aim of this work was to compare clinical aspects of fibromyalgia patients whose onset was related to traumatic events to idiopathic patients. One hundred and thirty fice consecutive patients were interviewed with a structured questionnaire about demographic aspects, work disability, pain characterization and the presence of symptoms not related to the locomotor system. Tender point count and dolorimetry were performed, as well as pain evaluation according to the visual analogue scale. The group of traumatic patients counted with 48 individuals, and presented with longer period of formal education (8,1 &#117; 4,1 x 5,3 &#117; 2,9 years; p < 0,001), higher count of tender points (16,1 &#117; 2,8 x &#117; 3,2; p = 0,047), shorter period since generalization of pain (5,6 &#117; 6,9 x 4,1 &#117; 2,6 years; p = 0,002), smaller prevalences of concentration difficulties (83,0% x 65,1%; p = 0,048) and abdominal cramps(45,8% x 26,4%; p = 0,036). There was an association between trauma and work disability. Any of remaining clinical aspects presented with statistically significant differences. We conclude that trauma imposes few clinical differences to fibromyalgia patients and does not explain the degree of work disability which is observed among them.