Even though most clinical information systems (CIS) today are technically sound, the number of successful implementations of these systems is low. For that reason, understanding the characteristics and challenges for organizations implementing CIS is now considered key to successful information technology deployment (Lorenzi & Riley, 1997). Although theory driven information systems models and CIS studies exist, an integrated model to predict a successful CIS has not been evaluated. The purpose of this research was to evaluate the ability of a theoretically-based integrated model of CIS success (CISSM) to predict a successful CIS from the clinicians' perspective. Data were collected and analyzed from 234 registered nurses in 4 hospitals who had used the Cerner PowerChart Admission Health Profile (AHP) longer than 3 months. Construct validity and internal consistency reliability of the 23-item online instrument were established. The results of stepwise multiple regression analyses provided tentative support for the CISSM model.

This thesis aimed to evaluate the feasibility and utility of a sickle cell disease registry for clinical patient management and research. Five hospitals out of nine in the North West London health region participated in the registry, with 78 percent coverage of the sickle cell disease population. There was 80% case ascertainment in participating hospitals. Aggregated anonymised demographic and diagnostic data was collected for all haemoglobinopathy patients. This provided the core dataset for quantifying prevalence of sickle cell and thalassaemia and mapping local hospital workloads and service requirements. Thirteen percent of HbSS adult patients were taking hydroxycarbamide. The cohort of patients treated with hydroxycarbamide was evaluated. Sixty two of the 80 patients started on treatment were included. Follow-up was censored after 9 years, totalling 249 person-years of data with a median follow-up of three years (IQR, 1-6). Results showed that haematological benefits were maintained in the long-term with treatment, but evidence of long-term clinical effectiveness was less strong. This appeared to be due to the patterns of clinical management in everyday practice. Patients tend to be treated with modest doses of hydroxycarbamide due to intolerance or inability to attain or maintain maximum tolerated dose. For example maximum tolerated dose was the aim of treatment for 91% of patients but it was achieved for 65% of participants. Non- compliance with treatment and monitoring schedule was the main reason for non- attainment. Results suggest that it is sensible to strive for maximum tolerated dose to ensure therapy remains effective, but with more realistic expectations of the dose patients can attain and maintain. Doses in adult patients average 20mg/kg/day and 25mg/kg/day in children. Adult patients may be able to achieve a higher dose, if there was more stringent monitoring and improved management of non-compliance. The North West London HU Sub-Registry proved useful for measuring long-term effectiveness and tolerability of hydroxycarbamide. Routinely collected data was utilized for both clinical management and research purposes. The novelty lay in examination of the nuances of routine clinical practice. An electronic patient record was developed as a clinical management tool. It is the first study reporting long-term outcomes for UK sickle cell disease patients on hydroxycarbamide. Findings should help clinicians devise effective treatment protocols and strategies for managing patients commenced on this therapy. Interventions need to be targeted at increasing utilisation, patient adherence and persistence with treatment. The electronic patient record could be used to maximise treatment benefit and improve adherence. More effective involvement of the multidisciplinary team and primary care colleagues in patient education and management should improve usage. Patients and carers need up to date and easy to assimilate information to make informed decisions about treatment options. Maintaining a SCD registry is challenging. Models which operate as clinical information systems provide an incentive for participation. These enable active involvement of local care providers in registry management and the ability to keep and utilize their own data. Clinicians require accurate and current data for patient management and to enable them to benchmark their local outcomes against national outcomes and care standards.

We present Information System Hazard Analysis (ISHA), a novel systemic hazard analysis technique focused on Clinical Information System (CIS)s. The method is a synthesis of ideas from United States Department of Defense Standard Practice System Safety (MIL-STD-882E), System Theoretic Accidents Models and Processes (STAMP) and Functional Resonance Analysis Method (FRAM). The method was constructed to fill gaps in extant methods for hazard analysis and the specific needs of CIS. The requirements for the method were sourced from existing literature and from our experience in analysis of CIS related accidents and near misses, as well as prospective analysis of these systems. The method provides a series of iterative steps which are followed to complete the analysis. These steps include modelling phases that are based on a combination of STAMP and FRAM concepts. The method also prescribes the use of triangulation of hazard identification techniques which identify the effects of component and process failures, as well as failures of the System Under Investigation (SUI) to satisfy its safety requirements. Further to this new method, we also contribute a novel hazard analysis model for CIS as well as a safety factor taxonomy. These two artifacts can be used to support execution of the ISHA method. We verified the method composition against the identified requirements by inspection. We validated the method’s feasibility through a number of case studies. Our experience with the method, informed by extant safety literature, indicates that the method should be generalizable to information systems outside of the clinical domain with modification of the team selection phase. / Graduate

Purpose: The purpose of this thesis is to determine what is known from the literature about the use of Clinical Information Systems (CIS’s) to support the information needs of individual health care providers (HCP), in particular the nurse case manager, and the inter-professional team providing chronic illness care in the community setting. Methods and Analysis: This is a scoping review with a pilot study for feasibility. MEDLINE, CINAHL, and WEB OF SCIENCE were searched up to April 2017. Reference lists and a citation manager of included studies were searched to identify further studies. Relevant full text papers were obtained and screened against inclusion criteria. Data from eligible articles was extracted using a predefined extraction form. Thematic narrative descriptions and descriptive statistics were used to summarize findings. Nurse case managers were recruited from diabetes and chronic kidney disease clinics for an exploratory questionnaire and follow up interview. Descriptive content analysis and nonparametric statistics were used to summarize findings of the pilot study. Results: 45 articles were identified meeting the inclusion criteria. Three themes emerged (1) patient information elements (2) visualization formats, techniques, and organization and (3) visualization of patient information elements. Diagnostics and observations were the most frequently mentioned information elements. Text was the main representation format. Four participants completed the pilot study initial questionnaire and one completed the follow up interview. There was 100% agreement for 11 elements. Six themes emerged (1) required information can change (2) information is required for different purposes (3) information required for communication is related to nurse case manager concerns (4) required information varies depending on the discipline reviewing it (5) certain types of information need to be grouped together and (6) it is difficult for a HCP to visualize what is necessary in a CIS without first seeing or trying it. Recommendations: The recommendations are a concept-oriented view customizable to the role of the HCP to display: diagnostics, outcomes and comparisons as graphs and colour coded, observations, medications, problem lists, clinical events, guidelines, the care plan, clinician to clinician communication, patient to clinician communication and clinician to patient communication as text, and clinical events as a timeline. Conclusion: This review and accompanying pilot study is a starting point for a framework of guidelines with the recommendations of proposed patient information elements and the visualization formats, techniques and organization. / Graduate

This paper deals with medical data extraction from electronic patient record (EPR) system. Most of the medical data are stored in patient record systems, and data that are much valuable for medical research. If a researcher wants to extract medical information today, it has to be done manually because the data are stored in unstructured textual format in a system created by hospital staff. There is no way of extracting data in structure way. This paper is going to introduce an information extraction application for EPR system that allows the researcher to set up a study with inclusion and parameters for extraction for retrospective surveys in a webuser-interface environment. Inclusion is what the researcher would like to study (a defined category or criteria) and parameters specify the characteristics of inclusion the criteria. Result of this application provides an extracted clinical data that is used for retrospective surveys, downloadable to an MS-Excel file.

Critical care nurses work in an environment rich in informative interactions. Although there have been post hoc self-report survey studies of nurses' information seeking, there have been no observational studies of the patterns and content of their on-duty information behavior. This study used participant observation and in-context interviews to describe 50 hours of the observable information behavior of a representative sample of critical care nurses in a 20-bed critical care hospital unit. The researcher used open, in vivo, and axial coding to develop a grounded theory model of their consistent pattern of multimedia interactions. The resulting Nurse's Patient-Chart Cycle describes nurses' activities during the shift as centering on a regular alternation with the patient and the patient's chart (various record systems), clearly bounded with nursing "report" interactions at the beginning and the end of the shift. The nurses' demeanor markedly changed between interactions with the chart and interactions with the patient. Other informative interactions were observed with other health care workers and the patient's family, friends and visitors. The nurses' information seeking was centered on the patient. They mostly sought information from people, the patient record and other digital systems. They acted on or passed on most of the information they found. Some information they recorded for their personal use during the shift. The researcher observed the nurses using mostly patient specific information, but they also used some social and logistic information. They occasionally sought knowledge based information. Barriers to information acquisition included illegible handwriting, difficult navigation of online systems, equipment failure, unavailable people, social protocols and mistakes caused by multi-tasking people working with multiple complex systems. No formal use was observed of standardized nursing diagnoses, nursing interventions, or nursing outcomes taxonomies. While the nurses expressed respect for evidence-based practice, there clearly was no time or opportunity for reading research literature (either on paper or online) while on duty. All participants expressed frustration with the amount of redundant data entry required of them. The results of this study have significant implications for the design of clinical information systems and library services for working critical care nurses.

A 15-facility healthcare organization utilized organizational change management techniques to aid with the adoption of a clinical information system to accomplish desired cultural transformation. The aim of this article was to provide a description of team member and physician attitudes toward change during conversion to a new clinical information system of electronic documentation. The tool developed and utilized was a change readiness survey to assess randomly selected team member and physician perceived readiness for the transition to an electronic documentation system. This article reviewed the rationale for using organizational change management techniques to facilitate adoption of a new clinical information system and discussed development of a change readiness survey tool. It explored the findings from the first 3 years of the survey.

Ο ηλεκτρονικός ιατρικός φάκελος κάθε πολίτη της χώρας αποτελείται από ιατρικές πληροφορίες που παράγονται γι' αυτόν, σε οποιονδήποτε φορέα παροχής υπηρεσιών υγείας. Σε κάθε Κέντρο Υγείας εγκαθίσταται πλήρης υποδομή για την τήρηση και ενημέρωση στοιχείων του ηλεκτρονικού ιατρικού φακέλου και για την πρόσβαση σε στοιχεία τα οποία τηρούνται σε άλλους φορείς παροχής υπηρεσιών υγείας όλων των κατοίκων που υπάγονται σε αυτό. Ο οικογενειακός και ο προσωπικός ιατρός υποχρεούται να ενημερώνει τους ηλεκτρονικούς ιατρικούς φακέλους των ασφαλισμένων που τον έχουν επιλέξει με τις πληροφορίες οι οποίες παράγονται από τον ίδιο. Ο πολίτης – ασθενής θα πρέπει να έχει και τη δυνατότητα να λαμβάνει σε ηλεκτρονική μορφή έναν προσωπικό ιατρικό φάκελο ο οποίος θα τον διευκολύνει στην πρόσβασή του στις υπηρεσίες υγείας της χώρας και στην άμεση εξασφάλιση παροχής αναγκαίων πληροφοριών και δεδομένων σχετικών με την υγεία του. Ο προσωπικός ηλεκτρονικός ιατρικός φάκελος μπορεί να περιέχει και άλλες προσωπικές πληροφορίες που αποτυπώνουν αναλυτικά την πιο πρόσφατη κατάσταση του ασθενούς (π.χ. μετά από έκτακτη εισαγωγή ή επίσκεψη σε ιατρό), οι οποίες θα μπορούν να τροποποιηθούν και από τον ίδιο. Η διπλωματική εργασία έχει ως στόχο την ανάπτυξη ενός τέτοιου προσωπικού ηλεκτρονικού ιατρικού φακέλου με την αξιοποίηση τεχνολογιών βάσεων δεδομένων και Διαδικτύου. / The electronic medical file of each citizen of country is constituted by medical information that is produced for him, in any institution of benefit of services of health. In each Centre of Health is installed complete infrastructure for the observation and briefing of elements of electronic medical file and for the access in elements which are observed in other institutions of benefit of services of health of all residents that be governed in this. The familial and personal doctor is compelled to inform the electronic medical files secured that have selected him with the information that is produced by the himself. The citizen - patient will be supposed has also the possibility receives in electronic form a personal medical file which will facilitate him in his access in the services of health of country and in the direct guarantee of benefit of necessary information and given relative with his health.The personal electronic medical file can contain also other personal information that impresses analytically the most recent situation of patient (eg after extraordinary import or visit in doctor), that might be also modified from himself. The diplomatic work aims at as the growth of such personal electronic medical file with the exploitation of technologies of bases of data and Internet.

INTRODUCTION: While mobile device use by physicians increases, there is an increased risk that errors committed while using mobile devices can lead to harm. This mixed-method study evaluates the effects of screen size on clinical users’ perceptions of medical application usability and safety when interfacing to critical patient information. In this research, two mobile devices are examined: iPhone® and the iPad®. METHOD: Eleven physicians and one nurse practitioner participated in a chart-review simulation using an app that was an end-point to an electronic health record. Screen-recording, video-recording and a think-aloud protocol were used to gather data during the simulation. Additionally, participants completed Likert-based questionnaires and engaged in semi-structured interviews. RESULTS: A total of 105 usability, usefulness and safety problems were recorded and analysed. A strong preference was found for the larger screen when reviewing patient data due to the large quantity of data and the increased display size. The smaller device was preferred due to the devices portability when participants needed to remain informed when they were away from the point of care. CONCLUSION: There is an association between screen size and the perceived safety of the handheld device. The iPad was perceived to be safer to use in clinical practice. Participants preferred the iPad® because of the larger size, not because they thought it was safer or easier to use. The iPhone® was preferred for its portability and its usefulness was perceived to increase with greater distance from the point of care. / Graduate

Les technologies de l’information et de la communication se sont considérablement développées dans tous les secteurs de l’économie. Dans le domaine de la santé, et tous particulièrement dans le secteur hospitalier, les investissements se sont considérablement accrus, notamment avec la mise en place de systèmes d’information clinique (SIC) intégrés. Les hypothèses derrière ces investissements sont que la mise en œuvre d’un SIC peut améliorer à la fois l’efficience d’un hôpital et la qualité des soins. Pour être validée, ces hypothèses nécessitent que soit mise au point une méthodologie de mesure du degré de mise en place d’un SIC, de l’efficience hospitalière puis de la qualité des soins. Ce travail est centré d’une part sur la méthodologie de mesure de l’utilisation d’un SIC et d’autre part sur la mesure de l’efficience hospitalière. Le cadre applicatif du travail est, dans le premier cas, le système d’information clinique de l’HEGP et dans le second les hôpitaux de court séjour de l’AP-HP dont fait partie l’HEGP. Après une étude de la littérature sur l’évaluation de l’utilisation et de de la satisfaction d’un SIC, la première partie de la thèse est organisée autour de deux études. Une première étude longitudinale de 2004 à 2014 permet d’analyser l’évolution de l’utilisation et de la satisfaction au travers d’un groupe multi professionnel d’utilisateurs et d’analyser leurs déterminants avec des méthodes d’équations structurelles. En post-adoption précoce (4 ans), l'utilisation du SIC, la qualité du SIC et l’utilité perçue (PU) expliquent 53% de la variance de la satisfaction. Dans la phase de post-adoption très tardive (>10 ans), l’effet de l’utilisation n’est plus significatif, par contre, la qualité du SIC, la confirmation des attentes et la PU sont les paramètres les plus liés à la satisfaction expliquant 86% de sa variance. Cependant, la satisfaction et la PU sont les facteurs les plus déterminants de l’intention de continuer, avec une forte influence indirecte de la qualité du système. Un modèle unifié est proposé et comparé aux modèles principaux de la littérature. La mesure de l’efficience des hôpitaux est effectuée avec un modèle économétrique dont le choix des variables a été effectué sur la base d’une revue systématique de la littérature. Trois catégories d’indicateurs d’entrée et trois catégories d’indicateurs de sorties sont utilisés. Les relations entre entrées et sorties sont analysées au travers une fonction de production (Translog) et d’un modèle paramétrique (Stochastic Frontier Analysis). Une diminution globale de l’efficience de 20 hôpitaux de court séjour de l’AP-HP sur la période 2009-2014 est observée dont les causes possibles sont discutées. La mise au point et la validation de modèles d’évaluation de l’utilisation des SIC d’une part et de mesure de l’efficience hospitalière devrait faciliter l’analyse des relations entre informatisation et efficience hospitalière, puis lorsque la même démarche aura été appliquée à la qualité des soins entre informatisation et qualité. / The information and communication technologies (ICT) have been developed in all economic sectors. In the healthcare field, and particularly in hospitals with the introduction of clinical information systems (CIS), investments have dramatically increased. The rationale for these investments is the improvement of both the hospital efficiency and the quality of the care delivered to patients after the deployment of a fully integrated CIS. In the aim to validate these relationships adapted methodologies, need to be designed and implemented. This thesis concentrates on the CIS maturity and hospital efficiency relationship. Material for testing the hypothesis come from several CIS evaluations performed at HEGP and data extracted from the decision analytics tools of Assistance Publique Hôpitaux de Paris (AP-HP). After a study of the literature on the use and satisfaction evaluation of a CIS, the first part of the thesis is organized around two main studies. A 14 years longitudinal study achieved between 2004 and 2014 analyzes the evolution of use and satisfaction and their determinants within a multi professional group of users using multiple regression techniques and structural equation methods. In early post-adoption (4 years), the CIS use, the CIS quality, and the CIS perceived usefulness (PU) explain 53% of the variance in user satisfaction. In the very late post-adoption phase (> 10 years), the effect of use on user satisfaction is no more significant. In contrast, the CIS quality, the confirmation of expectations, and the PU are the best determinants of satisfaction explaining 86% of its variance. In a second study focused on continuance intention, satisfaction and PU appear to be the best determinants of continuance intention, with a strong indirect influence of the CIS quality. A unified model is proposed and compared to the main models of the literature. The measurement of hospital efficiency was achieved with an econometric approach. Selection of indicators entered in the econometric model was performed on the basis of a systematic literature review. Three categories of input indicators and three categories of output indicators are considered. The relationship between the input and output indicators are analyzed through a Stochastic Frontier Analysis model. An overall decrease of the efficiency of the 20 short-stay hospitals of the AP-HP for the 2009-2014 period is observed and its possible causes are discussed. The development and validation of CIS use-satisfaction evaluation model combined with the analysis of the hospital efficiency evolution over time could be the first phase of a more global evaluation of the complex influence of IT introduction on hospital efficiency and the quality of care delivered to patients.