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

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Actuellement, les pratiques de Lean Management représentent un avantage compétitif pour la majorité des entreprises qui cherchent à améliorer leur performance dans un marché mondial très agressif. Le processus de mise en œuvre du Lean est très complexe ; il s'agit de se transformer en une nouvelle philosophie et de gérer l'entreprise - un changement de comportement. Ce document passe en revue la documentation relative aux pratiques de Lean Management et à l'incapacité de certaines entreprises à maintenir les résultats dans le temps, en particulier sur le décalage entre les objectifs du Lean et leurs efforts de mise en œuvre pour éliminer le gaspillage par l'amélioration des processus. La littérature a relevé plusieurs problèmes de gestion concernant ce problème, mais les principales raisons en sont, d'une part, une rupture des interfaces entre les aspects socio-techniques et, d'autre part, un besoin d'engagement réel de la part de la direction générale. Par conséquent, l'objectif de cet étude est de synthétiser et d'analyser ces difficultés Lean sur la base d'une pensée systémique dynamique et de proposer en plus, comme alternative à une proposition classique (linéarité) pour résoudre ces problèmes Leans, deux hypothèses : la contribution de la productivité qui réduit ces écarts, de manière plus globale ; en plus, sur l'approche de l'amélioration continue, qui permet de mesurer les"changements comportementaux" et encourage également la participation ; elle pose également le problème des performances chez des employés autonomes qui ont été documentés dans la documentation Lean / Currently, Lean Management Practices represents a competitive advantage for most companiestrying to raise their performance in a very aggressive global market. Lean’s implementationprocess is very complex; it means to transform into a new philosophy and managing the business- a behaviour change. This paper reviews the literature in relation to Lean managerial practicesand the incapacity for some companies to sustain the results over time; specifically about themisalignment among the Lean’s purposes with their implementation efforts to waste eliminationthrough the improvement of processes. The literature found several management issues regardingthis problem but the main reasons are firstly a breakdown interfaces between socio-technicalaspects and secondly, a need for real commitment from the top management. Consequently, thetarget of this paper is to synthesize and analyze those Lean difficulties based on dynamic systemthinking and, also, to propose two assumptions as an alternative to a conventional proposal(linearity) to solve this Leans’ problems: the contribution of productivity management whichnarrows these gaps, in a more holistic manner; in addition, based on the continuous improvementapproach as a metric to assess Lean’s "behaviour change" and also to encourage commitment; italso engages the performance dilemma throughout empowered workers that have beendocumented in the Lean literature