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Yes / Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits. Methods: Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in ‘back offices’ and meetings (102 hours). Findings were analysed thematically and synthesised in narratives. Results: Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements. Conclusions: If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations.

Electronic Patient Records (EPRs) are becoming standard tools in healthcare, lauded for improving patient access and outcomes. However, the healthcare professionals who work with, around, and despite these technologies in their daily practices often regard EPRs as troublesome. In order to investigate how EPRs can prompt such opposing opinions, this project examines the EPR as a collection of communication genres set in complex contexts. In this project, I investigate an EPR as it was used on the Nephrology ward at a large, Canadian, urban, paediatric teaching hospital. In this setting, this study investigates EPR-use in relation to the following aspects of context: (a) the visual rhetoric of the EPR's user-interface design; (b) the varied social contexts in which the EPR was used, including a diversity of professional collaborators who had varying levels of professional experience; (c) the span of social actions involved in EPR use; and (d) the other genres used in coordination with the EPR. <br /><br /> This qualitative study was conducted in two simultaneous stages, over the course of 8 months. Stage one consisted of a visual rhetorical analysis of a set of genres (including the EPR) employed by participants during a specific work activity. Stage two involved an elaborated, qualitative case study consisting of non-participant observations and semi-structured interviews. Stage two used a constructivist grounded theory methodology. A combination of theoretical perspectives -- Visual Rhetoric, Rhetorical Genre Studies, Activity Theory, and Actor-Network Theory -- supported the analysis of study data. This research reveals that participants routinely transformed EPR-based information into paper documents when the EPR's visual designs did not support the professional goals and activities of the participants. <br /><br /> Results indicate that healthcare professionals work around EPR-based patient information when that genre's visual organization is incompatible with professional activities. This study suggests that visual rhetorical analysis, complemented with observation and interview data, can provide useful insights into a genre's social actions. This research also examines the effects of such EPR-to-paper genre transformations. Although at one level of analysis, the EPR-to-paper-genre transformation may be considered inefficient for participants and so should be automated, at another level of analysis, the same transformation activity can be seen as beneficially supporting the detailed reviewing of patient information by healthcare professionals. <br /><br /> To account for this function in the transformation dysfunction, my research suggests that many contextual factors need to be considered during data analysis in order to construct a sufficiently nuanced understanding of a genre's social actions. To accomplish such an analysis, I develop a five-step approach to data analysis called 'context mapping. ' Context mapping examines genres in relation to the varied social contexts in which they are used, the span of social actions in which they are involved, and a range of genres with which they are coordinated. To conduct this analysis, context mapping relies heavily on theories of "genre ecologies" (Spinuzzi, 2003a, 2003b; Spinuzzi, Hart-Davidson & Zachry, 2004; Spinuzzi & Zachry, 2000) and "Knotworking" (Engestrom, Engestrom & Vahaaho, 1999). Context mapping's first three steps compile study data into results that accommodate a wide range of contextual analysis considerations. These three steps involve the use of a composite scenario of observation data, genre ecologies and the description of a starting point for analysis. The final two steps of this approach analyse results using the theory of Knotworking and investigate some of the implications of the patterns of genre use on the ward. <br /><br /> Through context mapping analysis, this study demonstrates that EPR-based innovations created by a study participant could result in the generation of other improvisations, in a range of genres, by the original participant and/or by other collaborators. These genre modifications had ramifications across multiple social contexts and involved a wide range of genres and associated social actions. Context mapping analysis demonstrates how the effects of participant-made EPR-based variations can be considered as having both beneficial and detrimental effects in the research site depending on the social perspective adopted. Contributions from this work are directed towards the fields of Rhetorical Genre Studies, Activity Theory research, and Health Informatics research, as well as to the research site itself. This study demonstrates that context mapping can support text-in-context style research in complex settings as a means for evaluating the effects of genre uses.

Electronic Patient Records (EPRs) are becoming standard tools in healthcare, lauded for improving patient access and outcomes. However, the healthcare professionals who work with, around, and despite these technologies in their daily practices often regard EPRs as troublesome. In order to investigate how EPRs can prompt such opposing opinions, this project examines the EPR as a collection of communication genres set in complex contexts. In this project, I investigate an EPR as it was used on the Nephrology ward at a large, Canadian, urban, paediatric teaching hospital. In this setting, this study investigates EPR-use in relation to the following aspects of context: (a) the visual rhetoric of the EPR's user-interface design; (b) the varied social contexts in which the EPR was used, including a diversity of professional collaborators who had varying levels of professional experience; (c) the span of social actions involved in EPR use; and (d) the other genres used in coordination with the EPR. <br /><br /> This qualitative study was conducted in two simultaneous stages, over the course of 8 months. Stage one consisted of a visual rhetorical analysis of a set of genres (including the EPR) employed by participants during a specific work activity. Stage two involved an elaborated, qualitative case study consisting of non-participant observations and semi-structured interviews. Stage two used a constructivist grounded theory methodology. A combination of theoretical perspectives -- Visual Rhetoric, Rhetorical Genre Studies, Activity Theory, and Actor-Network Theory -- supported the analysis of study data. This research reveals that participants routinely transformed EPR-based information into paper documents when the EPR's visual designs did not support the professional goals and activities of the participants. <br /><br /> Results indicate that healthcare professionals work around EPR-based patient information when that genre's visual organization is incompatible with professional activities. This study suggests that visual rhetorical analysis, complemented with observation and interview data, can provide useful insights into a genre's social actions. This research also examines the effects of such EPR-to-paper genre transformations. Although at one level of analysis, the EPR-to-paper-genre transformation may be considered inefficient for participants and so should be automated, at another level of analysis, the same transformation activity can be seen as beneficially supporting the detailed reviewing of patient information by healthcare professionals. <br /><br /> To account for this function in the transformation dysfunction, my research suggests that many contextual factors need to be considered during data analysis in order to construct a sufficiently nuanced understanding of a genre's social actions. To accomplish such an analysis, I develop a five-step approach to data analysis called 'context mapping. ' Context mapping examines genres in relation to the varied social contexts in which they are used, the span of social actions in which they are involved, and a range of genres with which they are coordinated. To conduct this analysis, context mapping relies heavily on theories of "genre ecologies" (Spinuzzi, 2003a, 2003b; Spinuzzi, Hart-Davidson & Zachry, 2004; Spinuzzi & Zachry, 2000) and "Knotworking" (Engestrom, Engestrom & Vahaaho, 1999). Context mapping's first three steps compile study data into results that accommodate a wide range of contextual analysis considerations. These three steps involve the use of a composite scenario of observation data, genre ecologies and the description of a starting point for analysis. The final two steps of this approach analyse results using the theory of Knotworking and investigate some of the implications of the patterns of genre use on the ward. <br /><br /> Through context mapping analysis, this study demonstrates that EPR-based innovations created by a study participant could result in the generation of other improvisations, in a range of genres, by the original participant and/or by other collaborators. These genre modifications had ramifications across multiple social contexts and involved a wide range of genres and associated social actions. Context mapping analysis demonstrates how the effects of participant-made EPR-based variations can be considered as having both beneficial and detrimental effects in the research site depending on the social perspective adopted. Contributions from this work are directed towards the fields of Rhetorical Genre Studies, Activity Theory research, and Health Informatics research, as well as to the research site itself. This study demonstrates that context mapping can support text-in-context style research in complex settings as a means for evaluating the effects of genre uses.

Despite rapid advances in technology, there is currently a complex, and somewhat disjointed approach to the way health information is collected, stored, and organized for both healthcare consumers and professionals. Incompatible electronic medical records from various healthcare providers add to the complexity of a system tasked with delivering a patient’s relevant medical information in a timely manner to the appropriate point of care. Personal health records (PHR) grew out of the efforts to produce an integrated electronic record to manage the multifaceted aspects of healthcare required by both healthcare consumers and professionals. PHRs are a transformative technology with the potential to alter patient-provider relationships in a way that produces a more efficient and cost effective healthcare system as a result of better patient outcomes. PHRs can potentially include a wide variety of users ranging from the lay public to clinical professionals. As such, it is important to identify potential user groups and their corresponding health information needs in order to design PHRs that maximize accessibility, usability, and clinical relevance. This study focused on laypeople who represented a wide age-range of individuals, evenly split in gender, with an above average level of computer literacy. Most of the participants had not used an electronic PHR prior to this study. However, after a hands-on session with PHR software, most participants found it to be easy to use, accompanied with the functionality they expected from such a system. Most participants were satisfied that an electronic PHR would meet their health information needs and would recommend the use of PHRs to family and friends. Anyone in the general public is a potential PHR user. However, this study found that individuals with chronic conditions and those with complex health needs had the most to gain from using a PHR as an integral part of their healthcare routine. This study also demonstrated that an individual’s health condition has a stronger influence on their perceptions about the usefulness of PHRs than does their demographic background (age, education, computer literacy). Finally, this study established that PHRs are considered by participants of the study to be useful tools in meeting their health information needs. / Graduate / 0723 / 0769 / 0984 / dguarin@uvic.ca

This study is a qualitative research on the faciliating and impeding factors that influence Hong Kong citizen's adoption of Electronic Health Record Sharing System (eHRSS), the principal electronic health record (EHR) system in Hong Kong.  A majority of the previous studies of EHR among information systems (IS) literature either focused within the institutional or technological perspectives, or on the perspectives of healthcare institutions or healthcare professionals. Little research has been done from citizens' perspective on factors of their adoption of EHR. There is also little research specific to Hong Kong's circumstances. This research aims to provide an enhanced understanding on the factors that influence citizens' EHR adoption through looking into eHRSS adoption in Hong Kong. It aims to provide contributions to bridge the knowledge gaps by providing a better understanding on adoption factors from citizens' perspective, and investigate into whether there are any unique factors applicable to Hong Kong. In this study, semi-structured interviews had been performed on participants covering various age groups to collect their views and opinions concering their adoption of eHRSS. With reference to theoretical constructs on user acceptance and adoption, this study identifies four facilitating factors for citizens' adoption of eHRSS, namely (i) knowledge, (ii) trust, (iii) perceived potential health benefits and (iv) flexibility and "stickiness" of continual use. Four impeding factors for citizens' non-adoption were also identified, namely (i) difficulty in registration, low level/lack of trust in EHR implementation, (iii) negativity on acceptance of new technology and (iv) perceived difficulty in usage.  In the concluding remarks, way forward for future research has been outlined. Practical recommendations have also been formulated for reference by relevant authorities in administering eHRSS in Hong Kong.

Since the 1990 the use of Electronic Patient Records (EPR) in health services has become increasingly prevalent world wide. EPR has become an important aspect of the continuous improvement of patient care. Transferring all patient records from paper based to electronic is now a priority for many health services. The research reported in this thesis is sponsored by Hamad Medical Corporation (HMC) to provide opportunity to explore the potential role for EPR in the Medical Records Department. The study has been designed to gain better understanding of the users perspectives with regard to the use of patient records. In order to analyse and understand the complex dynamic involved in the management and use of patient records, it was recognised that systems thinking offered an appropriate framework for this research. Soft System Methodology (SSM) was therefore applied to the analysis of the data and used to inform the development of a conceptual model. Using SSM in combination with the structured questionnaire survey and telephone semi-structured interview, triangulation of methods was achieved. Use of these generated rich data revealing for example the general dissatisfaction expressed with the existing manual patient records system, the lack of confidentiality, poor legibility, shortage of space and the frequent misfiling of records. The need to address these problems has informed the strategic plan for the development and implementation of EPR for HMC. The research has successfully addressed the stated aims and research questions and guided the formulation of proposals for improvements.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2015-04-30T12:12:17Z No. of bitstreams: 1 Bruno Vieira Cariry.pdf: 1014562 bytes, checksum: 695277f43d05386551478d66ceda3c29 (MD5) / Made available in DSpace on 2015-04-30T12:12:17Z (GMT). No. of bitstreams: 1 Bruno Vieira Cariry.pdf: 1014562 bytes, checksum: 695277f43d05386551478d66ceda3c29 (MD5) Previous issue date: 2013-12-05 / Introduction: The expansion of Family Health Estrategy in Brazil requires a construction of indicators that will evaluate the coherence of the approach effectively carried through and their guiding principles. The register in patient records is important for managers in health because it represents an indicator of quality in primary care. It can also work as an instrument of legal and ethical support for the professionals in charge of patient care, and helps in diagnosis and choosing of treatment. Objective: Evaluate the use of patient records by employees and managers of Primary Care in cities of hinterland of Paraiba state. Methodology: A semi-structured questionnaire with questions about biodemographic data and practical actions of healthcare professionals and managers towards the use of patient records was applied. Descriptive analysis was performed for all variables. Results: From analysis of the questionnaires, seven thematic categories that reflects the position of the group on the use of health records and their variables emerged: the need for a computerized system; incentive for use of records and information system; insatisfaction with manual registers; lack of knowledge of information systems; desire to classify all phases of care; uncertainty with regard to computerized system; and devaluation of records in Health. Conclusion: Managers and professionals must understand the importance of the use of patient records, in all their forms of presentation, for the process of health assistance managing as well as they should develop the stimuli in themselves and in their colleagues to make correct use of this instrument. / Introdução: A expansão da Estratégia de Saúde da Família no Brasil torna necessária a construção de indicadores que avaliem a coerência da abordagem efetivamente realizada e os seus princípios orientadores. O registro em prontuário é importante para os gestores em saúde, pois representa um indicador de qualidade da atenção básica. Também pode se constituir em instrumento para respaldo ético e legal aos profissionais responsáveis pelo cuidado ao paciente, bem como auxiliar na construção de diagnósticos e escolha de tratamentos empregados. Objetivo: Avaliar o uso de prontuários pelos profissionais e gestores da Atenção Básica em municípios do sertão paraibano. Metodologia: Foi aplicado entre os participantes um questionário semiestruturado com perguntas sobre dados biodemográficos e questões relacionadas a atitudes práticas do profissional de saúde ou gestor frente à utilização do prontuário. Foi realizada a análise descritiva de todas as variáveis. Resultados: Emergiram da análise sete temáticas de discussão que refletem o posicionamento dos grupos pesquisados sobre o uso de registros e saúde e suas variáveis: necessidade de sistema informatizado, incentivo para o uso do prontuário e sistema informatizado; insatisfação com o registro manual; pouco conhecimento sobre sistemas de informação; desejo de classificar todas as fases do atendimento, insegurança quanto ao sistema informatizado; e desvalorização dos registros em saúde. Conclusão: Gestores e profissionais devem compreender a importância de uso do prontuário, nas suas mais diferentes formas de apresentação, para o processo de gestão da assistência na saúde, bem como devem desenvolver estímulo em si mesmos e nos seus colegas para a correta utilização desse instrumento.

With the inevitable adoption of information technology into all areas of human pursuit, the potential benefits for health care should not be overlooked. In Australia, details of most health care encounters are currently recorded for administrative purposes. This results in an impressive electronic data-bank that could provide a national resource for health service evaluation. ¶ Evaluation of health services has become increasingly important to provide indicators of the benefits, risks and cost-effectiveness of treatments. However, if administrative data are to be used for this purpose, several questions must first be addressed: Are the current data collections accessible? What outcome measures can be derived from these data? Can privacy issues be managed? Could the quality of the data be improved? Is the existing infrastructure adequate to supply data for evaluation purposes? Could the existing system provide a basis for the development of an integrated health information system? ¶ The aims of the project were: · To examine the potential for using administrative data to generate outcome measures and surveillance indicators. · To investigate the logistics of gaining access to these data for the purpose of research. This to be achieved within the current ethical, political and financial framework. · To compare the Australian health-service data system with the current international state-of-the-art. · To develop suggestions for expansion of the present system as part of an integrated health record and information system. This system to manage patient records and provide data for quality management, treatment surveillance and cost-effectiveness evaluation as a routine activity. ¶ The thesis is presented in two parts. In the first part, a historical cohort study is described that involved patients with implantable medical devices. The potential to evaluate outcomes was investigated using all national health-service information currently available in electronic form. Record linkage techniques were used to combine and augment the existing data collections. Australia’s national health databases are to varying degrees, amenable to such linkage and cover doctor visits, pharmaceuticals, hospital admissions and deaths. The study focused on medical devices as an illustrative case but the results are applicable to the routine assessment of all medical and surgical interventions. ¶ For the Australian ‘Medical Devices study’, the records of 5,316 patients who had medical device implants in 1993-94 were selected from the archives of a major private health insurer. Five groups of medical implants were studied: heart valves, pacemakers, hips, vascular grafts and intra-optic lenses. Outcomes for these patients, including death, re-operation and health service utilisation, were compared and analysed. ¶ A comparison study was performed using data from the Manitoba Health database in Winnipeg, Canada. Manitoba provides a very similar demographic group to that found in Australia and is an example of a prototype integrated-health-information system. One of the principal advantages for research is that personally identified data about medical and hospital services are collected for all patients. Selection bias is eliminated because individual consent is not required for this type of research and all selected patients could be included in the study. ¶ The two studies revealed many barriers to the use of administrative data for health outcomes research. Service event data for the Australian cohort could be collected but only after long delays and hospital morbidity data were not available for the entire cohort. In contrast to the situation in Australia, the Manitoba data were both accessible and complete, but were lacking in detail in some areas. ¶ Analysis of the collected data demonstrated that without the addition of clinical data only general indications of trends could be deduced. However, with minimal supplementary clinical data, it was possible to examine differences in performance between brands of medical devices thus indicating one of the uses for this type of data collection. ¶ In the second part of the thesis, conclusions are presented about the potential uses and limitations of the existing system and its use as a basis for the development of a national Integrated Health Record and Information System (IHRIS). The need for the establishment of a systemic quality management system for health care is discussed. ¶ The study shows that linked administrative data can provide information about health outcomes which is not readily available from other sources. If expanded and integrated, the system that is currently used to collect and manage administrative data, could provide the basis for a national health information system. This system would provide many benefits for health care. Benefits would include the monitoring, surveillance and cost-effectiveness analysis of new and existing treatments involving medical devices, drugs and surgical procedures. An integrated health information system could thus provide for both clinical and administrative needs, while in addition providing data for research. ¶ Unfortunately, in Australia, the use of administrative data for this purpose is not currently feasible. The principal barrier is the existence of a culture within the Australian health care system which is not supportive of research and is deficient in quality and safety measures. ¶ Recent initiatives by both the Commonwealth and state governments have supported the introduction of measures to improve quality and safety in health care. It is argued here that an Integrated Health Record and Information System (IHRIS) would provide an essential component of any such scheme. The results of this study have important policy implications for health care management in both the administrative and clinical domains.

Background and aims: Most respiratory tract infections (RTI) are self-limiting. Despite this, they are associated with high antibiotic prescription rates in general practice in Sweden. The aim of this thesis was to evaluate the management of respiratory tract infections (RTIs) with particular emphasis on acute otitis media (AOM). Methods: Paper I: A prospective, open, randomized study of 179 children presenting with AOM and performed in primary care. Paper II &amp; III: Study of 6 years data from primary care in Kalmar County on visits for RTI, retrieved from electronic patient records. Paper IV: Observational, clinical study of 71 children presenting with AOM complicated by perforation, without initial use of antibiotics. Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II &amp; III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by &gt;10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP&lt;50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics. Results: Children with AOM who received PcV had some less pain, used fewer analgesics and consulted less, but the PcV treatment did not affect the recovery time or complication rate (I). Between 1999 and 2005, 240 445 visits for RTI were analyzed (II &amp; III). Antibiotics were prescribed in 45% of visits, mostly PcV (60%) and doxycycline (18%). Visiting rates for AOM and tonsillitis declined by &gt;10%/year, but prescription rates of antibiotics remained unchanged. For sore throat, 65% received antibiotics. Patients tested but without presence of S.pyogenes received antibiotics in 40% of cases. CRP was analyzed in 36% of consultations for RTI. At CRP&lt;50mg/l antibiotics, mostly doxycycline, were prescribed in 54% of visits for bronchitis. Roughly 50% of patients not tested received antibiotics over the years.Twelve of 71 children with AOM and spontaneous perforation completing the trial received antibiotics during the first nine days due to lack of improvement, one child after 16 days due to recurrent AOM and six had new incidents of AOM after 30 days (IV). Antibiotics were used more frequently when the eardrum appeared pulsating and secretion was purulent and abundant. All patients with presence of S.pyogenes received antibiotics.