Com o avanço tecnológico, a valorização da informação, o ritmo acelerado das mudanças e a globalização, características que fazem com que os hospitais (sejam eles, filantrópicos, governamentais ou privados), aliada às exigências cada vez maiores dos pacientes, aumentem a busca pela qualidade na prestação dos serviços. Sobre este pretexto, os hospitais integrantes do Sistema Único de Saúde (SUS), devem elaborar seus respectivos Censos Hospitalares e apresentar seus dados estatísticos ao Ministério da Saúde, baseado nas definições da Portaria no. 312 de 02 de maio de 2002. Estes indicadores não são os únicos necessários ou importantes para a gestão hospitalar, entretanto são considerados como informaçãoes básicas em uma instituição desta natureza. Contudo, a disponibilidade destas informações de forma contínua, sustentável e confiável não tem se mostrado uma tarefa trivial, principalmente devido alguns fatores: falta de registro, registro inadequado e incompleto, falta de padronização na aplicação do vocabulário médico e mudanças constantes nas rotinas administrativas. Em hospitais considerados de grande porte, este problema pode tomar uma extensão ainda maior. Por ser bastante complexo o Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, considerado o maior complexo hospitalar da América Latina, com aproximadamente 2.200 leitos e atendendo em média 6.000 pacientes ambulatoriais por dia, constitui um bom objeto para estudo de caso, pois permite que vários desafios em relação ao tratamento da informação, como por exemplo: compartilhamento, conectividade, interoperabilidade e integração, possam surgir de maneira mais acentuada a outros hospitais de menor complexidade. Segundo esta abordagem, o trabalho também pretende explorar o nível de contribuição dos diversos Sistemas de Informação Hospitalar utilizados pelo hospital na obtenção de variáveis, para a composição de informações que serão utilizadas como base para as ações administrativas e avaliação de desempenho. O alto grau de heterogeneidade presente nas soluções no domínio da saúde, distribuídos nos diferentes sistemas de informação, apontam para a v necessidade de compartilhar e troca informações entre ambientes heterogêneos. Neste contexto, a interoperabilidade tem um papel fundamental, pois permite a comunicação de forma transparente entre sistemas e ambientes heterogêneos, autônomos e distribuídos. Foram utilizados neste estudo documentos oficiais relativos aos sistemas de informação assistencial e sua gestão no HC-FMUSP, além de atas de Reuniões do Comitê de Tecnologia da Informação do hospital (CTI). Para a coleta de dados foi aplicada a técnica de entrevista semi-estruturada aos sujeitos responsáveis pelo Serviço de Arquivo Médico SAME de áreas estratégicas do hospital e do Núcleo de Informação em Saúde NIS. A crescente complexidade da assistência à saúde torna premente a necessidade de integração dos sistemas corporativos, bem como a adoção de padrões de registro e procedimentos, porém, não basta resolver as questões somente do ponto de vista tecnológico, o desafio é trabalhar estes problemas considerando toda a sua complexidade e articulando diferentes áreas, em busca de resultados efetivos / With the technological advance, the valuation of the information, the sped up rhythm of the changes and the globalization, characteristics that make with that the hospitals (they are they, philanthropy, governmental or private), allied to the bigger requirements each time of the patients, increase the search for the quality in the installment of the services. On this excuse, the integrant hospitals of the Only System of Health (SUS), must elaborate its respective Hospital Censuses and present its statistical data to the Health department, based on the definitions of governmental decree no. 312 of 02 of May of 2002. These pointers are not only the necessary ones or important for the hospital management, however they are considered as basic information in an institution of this nature. However, the availability of these information of continuous, sustainable and trustworthy form if has not shown a trivial task, mainly had some factors: lack of register, inadequate and incomplete register, constant lack of standardization in the application of the medical vocabulary and changes in the administrative routines. In considered hospitals of great transport, this problem can take an extension still bigger. Of to be sufficiently complex the Hospital of the Clinics of the College of Medicine of the University of Sao Paulo - HCFMUSP, considered the hospital complex greater of Latin America, with approximately 2,200 stream beds and taking care of in average 6,000 patients per day in the ambulatory, constitutes a good object for case study, therefore it allows that some challenges in relation to the treatment of the information, as for example: sharing, connectivity, interoperability and integration, can appear more of accented way to other hospitals of lesser complexity. According to this boarding, the work also intends to explore the level of contribution of the diverse systems of hospital information used by the hospital in the attainment of the variables, for the composition of information that will be used as base for the administrative cases and evaluation of performance. The high degree of present heterogeneity in the solutions in the domain of health distributed in the different systems of information, points with respect to the necessity to share and changes information between heterogeneous environments. In this vii context, the interoperability has a basic paper, therefore it allows to the communication of transparent form between systems and heterogeneous, independent and distributed environments. Official documents to the systems of health care information and its management in the HCFMUSP had been used in this study relative, beyond acts of meetings of the Committee of Technology of the Information of the hospital (CTI). For the collection of data the technique of interview half-structuralized to the responsible citizens for the Service of Medical Archive was applied - SAME of strategical areas of the hospital and the Nucleus of Information in Health - NIS. The increasing complexity of the health care becomes pressing the necessity of integration of the corporative systems, as well as the adoption of register standards and procedures, however, are not enough to only decide the questions of the technological point of view, the challenge are to work these problems considering all its complexity and articulating different areas, in search of effective results

In population health, the study of unobserved, or latent, heterogeneity in longitudinal data may help inform public health interventions. Growth mixture modeling is a flexible tool for modeling latent heterogeneity in longitudinal data. However, the application of growth mixture models to certain data types, namely, complex survey data and electronic health records, is underdeveloped. For valid statistical inferences in complex survey data, features of the sample design must be incorporated into statistical analysis. In electronic health records, the application of growth mixture modeling is challenged by high levels of missing values. In this dissertation, I have three goals: First, I propose a Bayesian growth mixture model for complex survey data in which I directly incorporate features of the complex sample design. Second, I extend a Bayesian growth mixture model of multiple longitudinal health outcomes collected in electronic health records to a shared parameter model that can account for dierent missing data assumptions. Third, I develop open-source software packages in R for each method that can be used for model tting, selection, and checking.

Electronic medical records (EMRs) or electronic health records have been in use for years in hospitals around the world as a time-saving system for patient record keeping. Despite its widespread use, some physicians disagree with the assertion that EMRs save time. The purpose of this study was to explore whether any time saved with the use of the EMR system was actually devoted by doctors to patient-care and thereby to improved patient-care efficiency. The conceptual support for this study was predicated employing the task-technology fit theory. Task-technology theorists argue that information technology is likely to have a positive impact in individual performance and production timeliness if its capabilities match the task that the user must perform. The research questions addressed the use of an EMR system as a time-saving device, its impact on the quality of patient-care, and how it has influenced patients' access to healthcare in Nigeria. In this research, a comparative qualitative case study was conducted involving 2 hospitals in Nigeria, one using EMRs and another using paper-based manual entry. A purposeful sample of 12 patients and 12 physicians from each hospital was interviewed. Data were compiled and organized using Nvivo 10 software for content analysis. Categories and recurring themes were identified from the data. The findings revealed that reduced patients' registration processing time gave EMR-using doctors more time with their patients, resulting in better patient care. These experiences were in stark contrast to the experiences of doctors who used paper-based manual entry. This study supports positive social change by informing decision makers that time saved by implementing EMR keeping may encourage doctors to spend more time with their patients, thus improving the general quality of healthcare in Nigeria.

Background: Cancer treatment and management require complicated clinical decision making to provide the highest quality of care for an individual patient. This is facilitated in part with ever-increasing availability of medications and treatments but hindered due to barriers such as access to care, cost of medications, clinician knowledge, and patient preferences or clinical factors. Although guidelines for cancer treatment and many symptoms have been developed to inform clinical practice, implementation of these guidelines into practice is often delayed or does not occur. Informatics-based approaches, such as clinical decision support, may be an effective tool to improve guideline implementation by delivering patient-specific and evidence-based knowledge to the clinician at the point of care to allow shared decision making with a patient and their family. The large amount of data in the electronic health record can be utilized to develop, evaluate, and implement automated approaches; however, the quality of the data must first be examined and evaluated. Methods: This dissertation addresses gaps the literature about clinical decision making for cancer care delivery. Specifically, following an introduction and review of the literature for relevant topics to this dissertation, the researcher presents three studies. In Study One, the researcher explores the use of clinical decision support in cancer therapeutic decision making by conducting a systematic review of the literature. In Study Two, the researcher conducts a quantitative study to describe the rate of guideline concordant care provided for prevention of acute chemotherapy-induced nausea and vomiting (CINV) and to identify predictors of receiving guideline concordant care. In Study Three, the researcher conducts a mixed-methods study to evaluate the completeness, concordance, and heterogeneity of clinician documentation of CINV. The final chapter of this dissertation is comprised of key findings of each study, the strengths and limitations, clinical and research implications, and future research. Results: In Study One, the systematic review, the researcher identified ten studies that prospectively studied clinical decision support systems or tools in a cancer setting to guide therapeutic decision making. There was variability in these studies, including study design, outcomes measured, and results. There was a trend toward benefit, both in process and patient-specific outcomes. Importantly, few studies were integrated into the electronic health record. In Study Two, of 180 patients age 26 years or less, 36% received guideline concordant care as defined by pediatric or adult guidelines, as appropriate. Factors associated with receiving guideline concordant care included receiving a cisplatin-based regimen, being treated in adult oncology compared to pediatric oncology, and solid tumor diagnosis. In Study Three, of the 127 patient records reviewed for the documentation of chemotherapy-induced nausea and vomiting, 75% had prescriber assessment documented and 58% had nursing assessment documented. Of those who had documented assessments by both prescriber and nurse, 72% were in agreement of the presence/absence of chemotherapy-induced nausea and vomiting. After mapping the concept through the United Medical Language System and developing a post-coordinated expression to identify chemotherapy-induced nausea and vomiting in the text, 85% of prescriber documentation and 100% of nurse documentation could be correctly categorized as present/absent. Further descriptors of the symptoms, such as severity or temporality, however, were infrequently reported. Conclusion: In summary, this dissertation provides new knowledge about decision making in cancer care delivery. Specifically, in Study One the researcher describes that clinical decision support, one potential implementation strategy to improve guideline concordant care, is understudied or under published but a promising potential intervention. In Study Two, I identified factors that were associated with receipt of guideline concordant care for CINV, and these should be further explored to develop interventions. Finally, in Study Three, I report on the limitations of the data quality of CINV documentation in the electronic health record. Future work should focus on validating these results on a multi-institutional level.

Healthcare associated infections are a considerable burden to the health care system. The affected patients have their prognosis worsened and demand more resources from hospitals. Furthermore, the bacteria causing these infections are becoming increasingly resistant to antibiotics while also becoming more deadly and contagious. Contributing with knowledge for stopping these infections is, therefore, important. This thesis reports on two projects centered on data collected at the University of Iowa Hospital and Clinics. The first project consisted in analyzing data collected by sensors that reported the location and hand washing behavior of health care workers. After extracting meaning from these radio signals, I studied two socially and epidemiologically relevant tasks: the inference of contact networks, which can be used to study the spread of infections in the hospital, and the study of associations between social pressure and hand washing, learning that effectively workers in proximity to others wash their hands more, but also that not all workers are as influential. In the second project, I developed a data mining method for analyzing medical records aimed at tackling the problems of class imbalance and high dimensionality, and applied it to predicting Clostridium Difficile infection. The learnt models performed better than the state of the art and even improved prediction as the onset of symptoms approached. The main contribution, however, was in the information discovered: certain events in certain orders increased the risk of developing the infection, suggesting that reversing these orders could improve prognosis.

<p>Mortality statistics are much used although their accuracy is often questioned. Producers of mortality statistics check for errors in death certification but current methods only capture obvious mistakes. This thesis investigates whether non-obvious errors can be found by linking death certificates to hospital discharge data.</p><p>Data: 69,818 deaths in Sweden 1995. Paper I: Analysing differences between the underlying cause of death from the death certificate (UC) and the main discharge condition from the patient’s last hospitalization (MDC). Paper II: Testing whether differences can be explained by ICD definitions of UC and MDC. Paper III: Surveying methods in 44 current studies on the accuracy of death certificates. Paper IV: Checking death certificates against case summaries for: i) 573 deaths where UC and MDC were the same or the difference could be explained; ii) 562 deaths where the difference could not be explained.</p><p>Results: In 54% of deaths the MDC differed from the UC. Almost two-thirds of the differences were medically compatible since the MDC might have developed as a complication of the UC. Of 44 recent evaluation studies, only 8 describe the methods in such detail that the study could be replicated. Incompatibility between MDC and UC indicates a four-fold risk that the death certificate is inaccurate. For some diagnostic groups, however, death certificates are often inaccurate even when the UC and MDC are compatible.</p><p>Conclusion: Producers of official mortality statistics could reduce the number of non-obvious errors in the statistics by collecting additional information on incompatible deaths and on deaths in high-risk diagnostic groups. ICD conventions contribute to the quality problem since they presuppose that all deaths are due to a single underlying cause. However, in an ageing population an increasing number of deaths are due to an accumulation of etiologically unrelated conditions.</p>

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

This project was undertaken to study the feasibility of constructing a briefcase size, portable computer system that could store and display the entire file of medical records of a practicing physician. The concept and most of the preliminary designs had been formulated previously. The project paper has given some of the design parameters as well as enough technical data to give the reader a clear idea of the project limits. No attempt was made to allow any reader enough technical information to construct a similar device.The concept of feasibility is herein explored, and the attempt is made to show that such a device is now constructed in sections and each section performs its function properly. Time did not allow the finishing touches to be worked out, but every aspect described in the "proposal" has been demonstrated to be feasible. Photographs in the Appendix depict the various aspects of construction.Ball State UniversityMuncie, IN 47306

One of the largest work areas for speech and language pathologists is intervention for children with speech and language disorders. The purpose of the present study was to describe and analyze the clinical management of language impairment in children by studying and comparing medical records and literature from the years 2000 and 2009. The present study is a sequel to two previously published papers by Christina Samuelsson (1997; 1999), in which medical records and literature from the 1920-, 60- and 70’s were studied and a paper by Helén Sämfors (2001), in which the years 1985 and 1995 were studied. The medical records used in the present study came from a medical ward for speech and language pathology at a university hospital in Sweden.   The results showed that significantly more children were referred to the clinic for speech and language problems in 2009 than in 2000, and more children were treated for their impairments. Also, the speech and language pathologists were more detailed when documenting anamnesis, status and therapy, and they devoted more time for investigating the children’s impairments in 2009.  In terms of literature, a development is observable concerning bilingualism, prosody, pragmatics and Swedish research regarding intervention for children with language impairments.

<p>Within the field of medical informatics, patient medical records are the sole source of information for dealing with clinical activities concerning the documentation, care, progression, and ongoing interactions between the patient and clinicians. Electronic or computer-based patient records (CPRs) have had a presence within health care in some form and magnitude for the past thirty years yet only recently have been incorporated in health care to a larger extent. Due to the wide variation of professions in health care, there is a problem of CPRs not being able to fulfill all the possibilities and demands the individual professionals need, since many CPRs are designed as a generic system, to be used across multiple professions.</p><p>The focus of this report is on the utilization of a generic CPR in a specialist clinical setting, i.e., a physical therapy clinic, and to analyze how the therapists utilize the different components and features in a generic CPR. The purpose of the evaluation was to investigate how viable the CPR was as a documentation tool and to which extent it supported the therapists in their clinical, documentation and delivery of care activities. In this study, a total of seven physical therapists participated in a post-usage evaluation of an existing CPR. The evaluation was achieved by interpretative research with open-ended interviews and observations. The results of the study showed that despite some shortcomings, the generic CPR was an effective tool for the clinicians, not only as a documenting aid, but also enabling them to quickly research the patients' prior diagnosis and treatment history, plan for future care, support decision-making and to communicate with other professionals so as to coordinate treatment and planning.</p>