Presentation Goals: Remember Why You Went into Medicine! Describe Patient-Centered Care Challenge you to become and remain Patient-Centered Review Patient-Centered EBM Implement (or Prevent) Attitude Shifts Give you hope!

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<p>Professionals and researchers have developed a number of strategies aimed at improving the quality and safety of medication use. However, studies continue to demonstrate persistent problems. For instance, the first paper in this thesis reveals the prevalence of potentially harmful drug combinations among elderly people in Europe. The following four papers focus on two professional groups and how they have approached safety and quality issues related to medication use: 1) the Swedish drug and therapeutics committees (DTCs) and 2) pharmacist involved in pharmaceutical care, an international movement. Qualitative research approaches were applied.</p><p>Papers II and III focus on the DTCs: analyses indicate a development of the perception of the DTC role over time. The focus of the activities was broadened – from targeting prescribing physicians to incorporating decision-makers and patients. However, a clear patient-centered perspective was generally lacking. Moreover, the findings indicate a shift in focus from cost aspects of medication use to an increased focus on quality and safety aspects. </p><p>In the studies addressing pharmaceutical care (Papers IV and V), the findings propose that different classification systems for drug-related problems had different characteristics which reflected differences in goals in the pharmaceutical care process. It was also found that the concept of pharmaceutical care was understood in different ways and that the perceptions were based on at least two different understandings of health and illness. First, a patient-centered perspective characterized by a <i>holistic</i> understanding of health and illness, and, second, an “EBM perspective” primarily based on a <i>biomedical</i> understanding of health and illness. </p><p>This thesis has disclosed new aspects of how two groups of professionals perceive their work towards improved quality and safety of medication use. A patient-centered perspective among healthcare collectives is not obvious; therefore, efforts and comprehensive strategies supporting change are necessary. Strategies should focus on challenging the traditional thought patterns and care approaches among professionals and students. </p>

Professionals and researchers have developed a number of strategies aimed at improving the quality and safety of medication use. However, studies continue to demonstrate persistent problems. For instance, the first paper in this thesis reveals the prevalence of potentially harmful drug combinations among elderly people in Europe. The following four papers focus on two professional groups and how they have approached safety and quality issues related to medication use: 1) the Swedish drug and therapeutics committees (DTCs) and 2) pharmacist involved in pharmaceutical care, an international movement. Qualitative research approaches were applied. Papers II and III focus on the DTCs: analyses indicate a development of the perception of the DTC role over time. The focus of the activities was broadened – from targeting prescribing physicians to incorporating decision-makers and patients. However, a clear patient-centered perspective was generally lacking. Moreover, the findings indicate a shift in focus from cost aspects of medication use to an increased focus on quality and safety aspects. In the studies addressing pharmaceutical care (Papers IV and V), the findings propose that different classification systems for drug-related problems had different characteristics which reflected differences in goals in the pharmaceutical care process. It was also found that the concept of pharmaceutical care was understood in different ways and that the perceptions were based on at least two different understandings of health and illness. First, a patient-centered perspective characterized by a holistic understanding of health and illness, and, second, an “EBM perspective” primarily based on a biomedical understanding of health and illness. This thesis has disclosed new aspects of how two groups of professionals perceive their work towards improved quality and safety of medication use. A patient-centered perspective among healthcare collectives is not obvious; therefore, efforts and comprehensive strategies supporting change are necessary. Strategies should focus on challenging the traditional thought patterns and care approaches among professionals and students.

SAMMANFATTNING Begrepp som patientcentrerad vård och helhetssyn i vården verkar användas av olika yrkeskategorier, inom hälso- och sjukvård, vilket kan ur kvalitetssynpunkt kan resultera i oklarheter inom den kliniska verksamheten. Syfte: Syftet med studien var att ta reda på vilka likheter och skillnader begreppen patientcentrerad vård och helhetssyn i vården har i den vetenskapliga litteraturen. Begreppen söktes i databaserna CINAHL och PubMed. Metod: Den metod som används för att jämföra begreppen byggde på Segestens begreppsanalysmodell. Resultat: Det som främst skiljer begreppet helhetssyn i vården från patientcentrerad vård är den andliga dimensionens centrala roll. Resultatet visar även att ett patientcentrerat arbetssätt förbättrar ekonomiska resultat. Det är främst sjuksköterskor som använder sig av helhetssyn i vården. Patientcentrerad vård verkar användas främst av läkare men begreppet förekommer även bland sjuksköterskor. Det gemensamma för begreppen då det gäller karaktäristika, förutsättningar och konsekvenser, är det som definieras i kraven på god vård enligt hälso- och sjukvårdslagen. Slutsats: sjukvårdspersonalens arbetssätt och syn på patienten utifrån patientcentrerad vård och helhetssyn i vården värnar om patientens bästa. Det som skiljer begreppen kan bero på vilken yrkesgrupp som undersökts i respektive studie. Studier av begreppet patientcentrerad vård uppfattas vara mer genomförda på läkargruppen samtidigt som helhetssyn i vården tycks vara mer förekommande då det gäller sjuksköterskegruppen. Fler studier behövs för att identifiera användningen av dessa begrepp och om deras betydelse i den kliniska verksamheten. / SUMMARY Concepts such as patient-centered care and holistic care seem to be used by different professions in healthcare. Looking upon these concepts from the aspect of quality, ambiguities can arise in clinical practice. Objective: The purpose of this study was to compare the similarities and differences between the concepts of patientcentered care and holistic care as they are presented in scientific literature. The terms were searched for in the databases CINAHL and PubMed. Method: The method used to compare the concepts was based on Segesten concept analysis model. Results: what differentiates the concept of holistic care of the patient-centered care is the central role of spiritual dimension. The results also show that a patient-centered care improves economic results. The term holistic health care seems to be used primarily by nurses, while patient-centered care seems to be used primarly by physicians, even though the term does occur among nurses. Conclusion: both patient-centered care and holistic care seem to have the same goal, that of preserving the patient`s best interests. What distinguishes the concepts may depend on the profession which was examined in each study. Research studies on patient-centered care have been carried out primarily on physicians, while studies on the holistic approach in health care have focused on nurses. More studies are needed to identify the use of these concepts and their importance in clinical practice. Nyckelord: Patient-centeredness, patient-centered care, holistic care, holistic nursing.

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Background: Patient experience is a crucial measure of patient-centeredness and quality care delivery. Digital health may contribute to patient experience by offering tailored and accessible avenues of care. Purpose: I explored how access to digital health, including telehealth, electronic health records, and online booking, may be associated with improved primary care experience for Ontario adults. Methods: This cross-sectional study included Ontario adults (16 years or older) who responded to waves 27 to 29 of the Health Care Experience Survey (HCES) between May 2019 and February 2020. Adults who did not see their primary care provider within the past 12 months or did not have a primary care provider were excluded. Outcomes included a summed patient experience score derived from five HCES experience-related questions and time to appointment for a health concern. Associations between outcomes and digital health interventions were tested through chi-square tests and logistic regression while adjusting for confounders and stratifying by health care utilization. Results: 3,700 participants met the inclusion criteria, where 2204 remotely communicated with their primary care provider (59.6%), 98 digitally accessed health records (2.6%), and 120 booked an appointment online (3.2%). We observed no significant associations between digital health tools and patient experience or time to appointments through chi-square tests. Participants with over three primary care visits in the past year who accessed online booking were 84% less likely to report poorer experience scores than participants without online booking access [Adjusted OR 0.16, 95% CI 0.02 – 0.56, p < 0.05]. Participants with three or fewer primary care encounters who accessed online booking, compared to the same reference group, were 72% less likely to report having a same or next day appointment with their primary care provider [Adjusted OR 0.25, 95% CI 0.08 – 0.64, p < 0.01]. Significant associations were observed between other sociodemographic factors and patient experience and access to care outcomes. Interpretation: The associations between digital health access and patient experience and access to care were inconsistent across different analyses. Despite experimental studies observing the benefits of digital health adoption in primary care, the effect is unclear in the real-world context. Furthermore, drawing conclusions on the relationship between digital health and quality care outcomes was limited due to the lack of adoption of digital health before the COVID-19 pandemic. As digital health adoption grows, future research should utilize the availability of further data to evaluate the effectiveness of digital health in Ontario primary care. / Thesis / Master of Science (MSc) / Patient outcomes such as experience and timeliness of care are frequently viewed as aims of quality health care. Although past studies indicate digital health supports quality care, the real-world effectiveness of digital health is underexplored in Ontario. This thesis aimed to explore relationships between real-world use of digital health in Ontario and primary care experience and access using survey data. This study found very few survey respondents used digital health before the COVID-19 pandemic. The primary care experience and access to care of adults who did use digital health did not differ very much from adults who did not use the technology. Some outcomes differed in adults who booked their primary care appointment online compared to those who did not; however, the study could not conclude on the relationship. Other personal factors such as age and residence area impacted the quality of primary care. This study was limited due to the lack of digital health users. Future studies should explore digital health's impact on patient outcomes beyond the pandemic.

Medical education aims at forming students’ professional identity. This includes skills and attitudes such as communication and teamwork skills. One of the thesis’ aims is to identify students’ typical difficulties with learning communication skills, and to understand how these affect their identity development. Group discussions of student-patient interviews were video-taped, and selected discussions were transcribed and analyzed. Students had difficulties in establishing trustful relationships with their patients, asking about sensitive topics, responding empathetically, and with applying formal structures to the consultation. Students’ professional identity was supported by peer students’ and teachers’ comments, which created a common language and fostered selfmonitoring abilities. Another aim was to study the relationship between students* attitude towards communication training, group learning, and their self-regulatory skills. In a survey study, established instruments were combined with a new questionnaire. Four medical schools participated – two with traditional and two with problem-based curricula – in Sweden and Germany. Statistical analyses revealed that female students were more positive towards learning communication skills than male students were. Good self-regulatory skills were related to a positive attitude towards group learning and clinical experience before academic studies. It was concluded that early clinical experience benefits students’ selfregulated learning, and promotes a positive attitude towards communication training. Awareness of typical difficulties can facilitate the acquisition of coping strategies. / Medicinsk undervisning syftar till att forma studenternas professionella identitet. Den omfattar färdigheter och inställningar, t.ex. kommunikationsfärdigheter och förmågan att arbeta i grupp. Ett av avhandlingens syften är att identifiera studenternas typiska svårigheter med att lära sig färdighet i läkar-patient kommunikation samt att förstå hur den påverkar identitetsutvecklingen. Gruppdiskussioner av student-patient intervjuer videofilmades, utvalda diskussioner transkriberades och analyserades. Studenterna berättade om svårigheter med att etablera förtroliga relationer med patienterna, att prata om känsliga ämnen, att visa empati och att använda intervjumallen. Den professionella identiten stöttas av studenternas och lärarnas kommentarer, vilka bidrar till ett gemensamt språk och förmågan till själviakttagelse. Andra syftet är att undersöka sambandet mellan studenternas inställningar till kommunikationsfärdigheter och grupparbete, samt deras förmåga till självreglerat lärande. I en enkätundersökning kombinerades befintliga instrument med ett nytt frågeformulär. Fyra medicinska fakulteter deltog: två med traditionella och två med problembaserade undervisningsmetoder, en av varje i Sverige och i Tyskland. Statistiska analyser visade att kvinnliga studenter är, jämfört med manliga, mer positiva till att träna upp kommunikativa färdigheter. Förmågan till självreglerat lärande var relaterad till en positiv inställning till gruppinlärande och till klinisk erfarenhet innan studierna påbörjas. Slutsatsen är att tidig klinisk erfarenhet fostrar självstyrt lärande och en positiv inställning till kommunikationsträning. Medvetenhet om typiska svårigheter kan underlätta för studenter att anamma strategier att hantera dessa.

The U.S. Congress has made health information technology a central component of the national quest to improve health care delivery. The problem addressed in this study was the uncertainty among healthcare providers regarding the benefits of health care information technology adoption relative to healthcare delivery processes and outcomes. The purpose of the study was to understand the effectiveness of information technology as perceived by healthcare providers. The research questions were designed to investigate the relationship between health information technology and organizational effectiveness, exchange of information, organizational process, organizational productivity, and direct personal care. Sociotechnical systems theory and Donabedian's framework for health care quality evaluation were the theoretical bases for this quantitative study. Data were provided through anonymous online survey of 116 healthcare workers, and analyzed using multiple regression and Spearman's correlation coefficient. The results of the study showed a statistically significant positive correlation between organizational effectiveness, organizational exchange of information, organizational process, organizational productivity, and healthcare information technology. No statistically significant correlation existed between personal care and health information technology. These findings suggest that providers' frequent use of healthcare information technology, like telemedicine, makes patients less involved. The implications for social change include enabling healthcare providers to develop an efficient and effective way to engage with patients, in order to achieve effective patient-centered organization.

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