The overall aim of the research was to produce a validated framework for a Malaysian integrated and distributed telemedicine system. The framework was constructed so that it was capable of being useful in retrieving and storing a patient’s lifetime health record continuously and seamlessly during the downtime of the computer system and the unavailability of a landline telecommunication network. The research methodology suitable for this research was identified including the verification and validation strategies. A case study approach was selected for facilitating the processes and development of this research. The empirical data regarding the Malaysian health system and telemedicine context were gathered through a case study carried out at the Ministry of Health Malaysia (MOHM). The telemedicine approach in other countries was also analysed through a literature review and was compared and contrasted with that in the Malaysian context. A critical appraisal of the collated data resulted in the development of the proposed framework (MyTel) — a flexible telemedicine framework for the continuous upkeep of patients’ lifetime health records. Further data were collected through another case study (by way of a structured interview in the outpatient clinics/departments of MOHM) for developing and proposing a lifetime health record (LHR) dataset for supporting the implementation of the MyTel framework. The LHR dataset was developed after having conducted a critical analysis of the findings of the clinical consultation workflow and the usage of patients’ demographic and clinical records in the outpatient clinics. At the end of the analysis, the LHR components, LHR structures and LHR messages were created and proposed. A common LHR dataset may assist in making the proposed framework more flexible and interoperable. The first draft of the framework was validated in the three divisions of MOHM that were involved directly in the development of the National Health ICT project. The division includes the Telehealth Division, Public and Family Health Division and Planning and Development Division. The three divisions are directly involved in managing and developing the telehealth application, the teleprimary care application and the total hospital information system respectively. The feedback and responses from the validation process were analysed. The observations and suggestions made and experiences gained advocated that some modifications were essential for making the MyTel framework more functional, resulting in a revised/final framework. The proposed framework may assist in achieving continual access to a patient’s lifetime health record and for the provision of seamless and continuous care. The lifetime health record, which correlates each episode of care of an individual into a continuous health record, is the central key to delivery of the Malaysian integrated telehealth application. The important consideration, however, is that the lifetime health record should contain not only longitudinal health summary information but also the possibility of on-line retrieval of all of the patient’s health history whenever required, even during the computer system’s downtime and the unavailability of the landline telecommunication network.

No description available.

Patient medical records are a valuable resource that can be used for many purposes including managing and planning for future health needs as well as clinical research. Health databases such as the clinical practice research datalink (CPRD) and many other similar initiatives can provide researchers with a useful data source on which they can test their medical hypotheses. However, this can only be the case when researchers have a good set of hypotheses to test on the data. Conversely, the data may have other equally important areas that remain unexplored. There is a chance that some important signals in the data could be missed. Therefore, further analysis is required to make such hidden areas become more obvious and attainable for future exploration and investigation. Data mining techniques can be effective tools in discovering patterns and signals in large-scale patient data sets. These techniques have been widely applied to different areas in medical domain. Therefore, analysing patient data using such techniques has the potential to explore the data and to provide a better understanding of the information in patient records. However, the heterogeneity and complexity of medical data can be an obstacle in applying data mining techniques. Much of the potential value of this data therefore goes untapped. This thesis describes a novel methodology that reduces the dimensionality of primary care data, to make it more amenable to visualisation, mining and clustering. The methodology involves employing a combination of ontology-based semantic similarity and principal component analysis (PCA) to map the data into an appropriate and informative low dimensional space. The aim of this thesis is to develop a novel methodology that provides a visualisation of patient records. This visualisation provides a systematic method that allows the formulation of new and testable hypotheses which can be fed to researchers to carry out the subsequent phases of research. In a small-scale study based on Salford Integrated Record (SIR) data, I have demonstrated that this mapping provides informative views of patient phenotypes across a population and allows the construction of clusters of patients sharing common diagnosis and treatments. The next phase of the research was to develop this methodology and explore its application using larger patient cohorts. This data contains more precise relationships between features than small-scale data. It also leads to the understanding of distinct population patterns and extracting common features. For such reasons, I applied the mapping methodology to patient records from the CPRD database. The study data set consisted of anonymised patient records for a population of 2.7 million patients. The work done in this analysis shows that methodology scales as O(n) in ways that did not require large computing resources. The low dimensional visualisation of high dimensional patient data allowed the identification of different subpopulations of patients across the study data set, where each subpopulation consisted of patients sharing similar characteristics such as age, gender and certain types of diseases. A key finding of this research is the wealth of data that can be produced. In the first use case of looking at the stratification of patients with falls, the methodology gave important hypotheses; however, this work has barely scratched the surface of how this mapping could be used. It opens up the possibility of applying a wide range of data mining strategies that have not yet been explored. What the thesis has shown is one strategy that works, but there could be many more. Furthermore, there is no aspect of the implementation of this methodology that restricts it to medical data. The same methodology could equally be applied to the analysis and visualisation of many other sources of data that are described using terms from taxonomies or ontologies.

The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization. Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom. After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today. Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care. In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

Introduction and background: The use of Electronic Health Records (EHRs) sometimes referred to as Electronic Patient Care Records (ePCRs) amongst health and social care providers is increasing.  Many countries are anticipating the benefits of maintaining patients’ records in one place to facilitate real time access by clinicians and other health and social care providers at the point of need; thereby saving resources, seeking to work more efficiently and indeed taking advantage of the rapid advancement in technology to enhance communication.   Objectives:  Investigate challenges facing implementation of England’s EHRs programme by reviewing two design research approaches. Link the findings to possible barriers to augmenting the scope of the use of EHRs in the pre-hospital care at the Ambulance Service under study.   Approach and Methodology:  Literature review on design approaches to rolling out EHRs systems of 4 countries. Followed by an examination available information on England’s EHRs implementation programme whilst considering the findings to draw out any similarities and differences with each of the countries examined. Follow-on enquiry through interviews whose results help draw relationships between success and design/implementation methodologies. In this systematic review, several article sources are used, including ERIC, IEEE Xplore, ACM Digital Library, Google Scholar and Springer Link. Examples of cases are selected after reading titles and abstracts to decide whether the articles are peer reviewed, and relevant to the subject of enquiry. In addition, for articles to be selected they have had to meet the following criteria, a) written in English, b) full text is available online, c) had to have had primary empirical data, and d) focused on EHR implementation programmes.  Iinterviews are carried out to gather first hand data for review, analysis and evaluation, to inductively make an end point explanation of patterns in EHRs implementation programmes.   Findings:  Of the examples of EHRs systems across Europe and North America reviewed, independent and dependent variables closest to the research questions and hypotheses are identified, narrowing them down to design and implementation approaches to make probable causal link to implementation of EHRs system in England in general and the Ambulance Service in particular.   Conclusion: A connection with England’s EHRs implementation programme is made as the study alludes success to user driven bespoke solution as opposed to technology engineered systems. The study concludes that the design approach adopted by a country plays a significant role in gaining ‘buy-in’ when implementing EHRs systems. Subsequently recommendations are made to explore participatory design as a key promoter to ensure uptake of EHRs systems across main stakeholder groups whilst making a specific case for augmenting the scope of using ePCRs at  the Ambulance Service provider in England. Furthermore, the conclusions deduce direct correlation to rollout progress and appetite for using EHRs in healthcare generally and could in theory influence behavior and attitudes that could foster acceptance and improve chances of successful implementation of ePCRs programme in England in general and the Ambulance Service under study.        Keywords: Electronic Health Records (EHRs), Electronic Patient Care Records (ePCRs), Design Approach, Ambulance Service (Pre-Hospital Care), Design Approach

<p>Den dokumentation som görs i patientjournaler får allt större betydelse för patientens säkerhet och delaktighet samt för uppföljning och utveckling av vårdens kvalitet. IT-stöd ökar informationens tillgänglighet, men studier visar på brister vad gäller struktur och innehåll.</p><p>Syftet med denna studie var att kartlägga i vilken omfattning dubbeldokumentation förekom i den tvärprofessionella, elektroniska patientjournalen, relaterat till sjuksköterskans dokumentation (delstudie I), samt att undersöka personals uppfattningar om dubbeldokumentation och värdet av att använda egen och annan professions dokumentation (delstudie II).</p><p>Studien genomfördes på ett länsdelssjukhus där datorjournaler använts i ca 10 år. Trettio strokepatienters journaler analyserades utifrån VIPS-modellens sökord och arbetsterapeuter, läkare, sjukgymnaster och sjuksköterskor (N = 111) besvarade en studiespecifik enkät.</p><p>Resultatet visade att 15 % av innehållet i omvårdnadsdokumentationen (exklusive epikris) också fanns dokumenterat på annan plats i journalen, en eller flera gånger. Av omvårdnadsanamnesernas innehåll var 43 % dubbeldokumenterat. Motsvarande andel för omvårdnadsstatus och omvårdnadsåtgärder var 6 % respektive 10 %. När det gäller omvårdnadsepikriserna var 41 % av innehållet även dokumenterat i annan professions epikris. Dubbeldokumentationer förekom oftare mellan sjuksköterska och läkare än mellan sjuksköterska och arbetsterapeut/sjukgymnast. Samtliga professioner ansåg det värdefullt att kunna ta del av varandras dokumentation. Läkarens dokumentation följdes i stor utsträckning av alla. Arbetsterapeuter, sjukgymnaster och sjuksköterskor följde varandras dokumentation i stor utsträckning. Det var vanligare att man sökte specifik information än läste dokumentationen för att skaffa sig en helhetsbild. Sjuksköterskor sökte också ofta information för att i sin tur lämna denna vidare. Dubbeldokumentation ansågs förekomma mest inom journalens anamnesdel. Tänkbara orsaker till dubbeldokumentation ansågs vara att man inte läser vad andra har dokumenterat, att man vill visa vad som gjorts samt att diktaten skrivs in för sent. Vid jämförelse mellan sjuksköterskor med äldre utbildning respektive de med utbildning enligt 1993 års studieordning visades att sjuksköterskor med äldre utbildning instämde i högre utsträckning till att dubbeldokumentation ofta förekommer mellan läkare och sjuksköterska.</p><p>För att undvika onödig dubbeldokumentation krävs, förutom att aktuell information finns tillgänglig, att roller och ansvarsförhållanden mellan professionerna tydliggjorts.</p> / <p>The documentation made in patients’ charts is becoming of greater importance for the safety and involvement of patients and for the follow up and development of the quality of care. IT support increases the accessibility of information, but studies even show deficits pertaining to structure and content. The aim for this study was to survey to what extent double documentation occurs in multiprofessional, electronic patient charts, related to the nurse’s documentation and to investigate staffs’ understanding of the value and usage of other professionals’ documentation.</p><p>The study was conducted at a county hospital where computer charts have been in use for about 10 years. Thirty stroke patients’ charts were analysed on the basis of the VIPS models key words and occupational therapists, physicians, physiotherapists, and nurses completed a study specific survey.</p><p>The results showed that 15% of the content in nursing care documentation (excluding epicrisis) was also documented in other places in the chart, one or more times. Of the content of the nursing anamnesis 43% were double documented. The corresponding share of the nursing status and nursing interventions were 6% respectively 10%. When it comes to nursing epicrisis 41% of the content was also documented in other professionals’ epicrisis. Double documentation occurs more often between nurses and physicians than between nurses and occupational therapists/physiotherapists.</p><p>All of the occupations considered that it is valuable to be able to take part in each others documentation. Physicians’ documentation was followed to a great extent by all. Occupational therapists, physiotherapists, and nurses followed each others documentation to a great extent. It was more common to seek specific information that to read the documentation in order to acquire an overall picture. Nurses sought also often information which in turn was given to others. Double documentation was considered to occur mostly in the section of the chart for anamnesis. Conceivable reasons for double documentation were considered to be caused by not reading what others had documented, to show what had been done, and that dictation was written in too late. At a comparison between nurses with an older education and those with an education according to the 1993 curriculum showed that nurses with an older education agreed to a greater extent that double documentation occurred between physicians and nurses.</p><p>Avoiding unnecessary double documentation demands, besides that current information is available, that the conditions of rolls and responsibilities between professionals are clarified.</p>

Den dokumentation som görs i patientjournaler får allt större betydelse för patientens säkerhet och delaktighet samt för uppföljning och utveckling av vårdens kvalitet. IT-stöd ökar informationens tillgänglighet, men studier visar på brister vad gäller struktur och innehåll. Syftet med denna studie var att kartlägga i vilken omfattning dubbeldokumentation förekom i den tvärprofessionella, elektroniska patientjournalen, relaterat till sjuksköterskans dokumentation (delstudie I), samt att undersöka personals uppfattningar om dubbeldokumentation och värdet av att använda egen och annan professions dokumentation (delstudie II). Studien genomfördes på ett länsdelssjukhus där datorjournaler använts i ca 10 år. Trettio strokepatienters journaler analyserades utifrån VIPS-modellens sökord och arbetsterapeuter, läkare, sjukgymnaster och sjuksköterskor (N = 111) besvarade en studiespecifik enkät. Resultatet visade att 15 % av innehållet i omvårdnadsdokumentationen (exklusive epikris) också fanns dokumenterat på annan plats i journalen, en eller flera gånger. Av omvårdnadsanamnesernas innehåll var 43 % dubbeldokumenterat. Motsvarande andel för omvårdnadsstatus och omvårdnadsåtgärder var 6 % respektive 10 %. När det gäller omvårdnadsepikriserna var 41 % av innehållet även dokumenterat i annan professions epikris. Dubbeldokumentationer förekom oftare mellan sjuksköterska och läkare än mellan sjuksköterska och arbetsterapeut/sjukgymnast. Samtliga professioner ansåg det värdefullt att kunna ta del av varandras dokumentation. Läkarens dokumentation följdes i stor utsträckning av alla. Arbetsterapeuter, sjukgymnaster och sjuksköterskor följde varandras dokumentation i stor utsträckning. Det var vanligare att man sökte specifik information än läste dokumentationen för att skaffa sig en helhetsbild. Sjuksköterskor sökte också ofta information för att i sin tur lämna denna vidare. Dubbeldokumentation ansågs förekomma mest inom journalens anamnesdel. Tänkbara orsaker till dubbeldokumentation ansågs vara att man inte läser vad andra har dokumenterat, att man vill visa vad som gjorts samt att diktaten skrivs in för sent. Vid jämförelse mellan sjuksköterskor med äldre utbildning respektive de med utbildning enligt 1993 års studieordning visades att sjuksköterskor med äldre utbildning instämde i högre utsträckning till att dubbeldokumentation ofta förekommer mellan läkare och sjuksköterska. För att undvika onödig dubbeldokumentation krävs, förutom att aktuell information finns tillgänglig, att roller och ansvarsförhållanden mellan professionerna tydliggjorts. / The documentation made in patients’ charts is becoming of greater importance for the safety and involvement of patients and for the follow up and development of the quality of care. IT support increases the accessibility of information, but studies even show deficits pertaining to structure and content. The aim for this study was to survey to what extent double documentation occurs in multiprofessional, electronic patient charts, related to the nurse’s documentation and to investigate staffs’ understanding of the value and usage of other professionals’ documentation. The study was conducted at a county hospital where computer charts have been in use for about 10 years. Thirty stroke patients’ charts were analysed on the basis of the VIPS models key words and occupational therapists, physicians, physiotherapists, and nurses completed a study specific survey. The results showed that 15% of the content in nursing care documentation (excluding epicrisis) was also documented in other places in the chart, one or more times. Of the content of the nursing anamnesis 43% were double documented. The corresponding share of the nursing status and nursing interventions were 6% respectively 10%. When it comes to nursing epicrisis 41% of the content was also documented in other professionals’ epicrisis. Double documentation occurs more often between nurses and physicians than between nurses and occupational therapists/physiotherapists. All of the occupations considered that it is valuable to be able to take part in each others documentation. Physicians’ documentation was followed to a great extent by all. Occupational therapists, physiotherapists, and nurses followed each others documentation to a great extent. It was more common to seek specific information that to read the documentation in order to acquire an overall picture. Nurses sought also often information which in turn was given to others. Double documentation was considered to occur mostly in the section of the chart for anamnesis. Conceivable reasons for double documentation were considered to be caused by not reading what others had documented, to show what had been done, and that dictation was written in too late. At a comparison between nurses with an older education and those with an education according to the 1993 curriculum showed that nurses with an older education agreed to a greater extent that double documentation occurred between physicians and nurses. Avoiding unnecessary double documentation demands, besides that current information is available, that the conditions of rolls and responsibilities between professionals are clarified.

I denna kvalitativa studie ombads 5 psykodynamiskt inriktade terapeuter att i skrift beskriva sin upplevelse av journalskrivning. Materialet analyserades med hjälp av EPP-(Empirical Phenomenological Psychological) metoden. Resultatet lyfter fram generella kännetecken och särskiljande drag inom upplevelsen av journalskrivning. Gemensamt för terapeuternas upplevelse är att journalskrivandet har olika funktioner. Det är ett arbetsverktyg för att kommunicera med andra vårdgivare, det omfattas av vissa styrfaktorer och en upplevd osäkerhet om journalskrivandets regelverk. Det egna journalskrivandet uppvisar en hög värdering av den personliga upplevelsen och känslan av att utlämna patienten i journalen. Däremot skiljer sig terapeuterna åt i sättet att hantera känslor av konflikt inom journalskrivandet vilket påverkar den egna upplevelsen av journalskrivning. Två upplevda alternativ att hantera konflikt presenteras. I den ena gruppen försöker terapeuterna att omforma journalen så att den bättre passar den egna terapeutiska identiteten. När det inte längre är möjligt uttrycks en känsla av att något som inte går att ersätta försvinner. I den andra gruppen ökar terapeuterna sin reflektion och bearbetning av de delar inom journalskrivningen som terapeuten upplever orsakar konflikt, vilket bidrar till en känsla av att något positivt tillförts den terapeutiska identiteten. / In this qualitative study 5 psychotherapists with psychodynamic specialization were asked to reflect on their experiences concerning the writing of patient records. This material was analyzed using the so-called EPP-method (empirical phenomenological psychological method). The results show both general and distinctive features in how different therapists feel about their patient records routines. All agree that the process of writing patient records contains a number of different functions. It is a tool to communicate with other medical staff and facilities; it is influenced by certain control factors and also by experienced uncertainty concerning the formal rules related to the routines of patient records. Record routines show a high degree of evaluation of personal emotions and experiences together with a fear of revealing too much information about a patient. On the other hand, there is a substantial distinction in how different therapists handle their feelings of conflict related to medical records. The study presents two different possible ways of handling such conflicts. One group of therapists try to reshape the medical journal to make it better adjusted to their personal therapeutic identity. When that becomes impossible they express a feeling of something being lost. In the second group the therapists work harder with those parts in patient record routines that are causing them problems. This results in a feeling that something valuable is being added to their therapeutic identity.

eHealth Strategies in countries have shown a trend that countries are moving to Electronic Health Records(EHR). EHR implementation is expected to produce benefits for patients, professionals, organisations, and the population as a whole. The use of some format of an Electronic Health Record is used by many countries and others are in the implementation or planning phases. South Africa has kicked of the project to implement a national EHR as part of the national eHealth Strategy. This study aims to analyse the key success factors from other EHR implementation projects and evaluate if South Africa is ready to implement an EHR.

Changes to the technological landscape of the National Health Service (NHS) in the UK have often raised debates on information privacy and patient confidentiality. This has been especially pertinent in the context of HIV health services, where patient records have been historically segregated from hospital notes to protect confidentiality and account for the nature of the condition as a stigmatised terminal illness. However, as current anti-retroviral treatment extends life expectancy, HIV is increasingly managed in ways similar to other chronic conditions and integrated patient management has been proposed as best practice. This shift offers a unique opportunity to study reconfigurations of privacy and confidentiality practices from the perspective of data users. This thesis focuses on a technological integration project between the stand-alone systems used in two HIV specialist outpatient centres and the centralised Electronic Patient Records (EPR) of their respective NHS Hospital Trusts. The case study methodology draws on 46 semi-structured interviews with health and IT professionals, supplemented by an analysis of organisational documents and observation of work practices over a period of six months in the two clinics. In weaving together different theoretical concepts, this thesis contributes to an in-depth, empirically informed understanding of privacy and confidentiality practices in healthcare. Firstly, by looking at how HIV practitioners cultivate their professional identities at the intersection of general medical and HIV-specific confidentiality, this thesis argues that identity work is an important component in the reconfiguration of privacy practices. Secondly, this research draws attention to the role of political negotiations for privacy change, as HIV professionals and EPR developers came in conflict over the ethics of the technological integration project in the hospitals studied here. Thirdly, this thesis illustrates how confidentiality practices are shaped within the co-construction of information infrastructures and medical work, especially in relation to HIV normalisation. A number of implications for practice and policy also emerge from this study.