Background: Despite barriers such as financial and infrastructural challenges, there are many successfully implemented eHealth projects in Low- and Middle-Income Countries (LMICs). However, project scale-up and sustainability remains a pressing issue. This study analyses in detail an example of one such successful eHealth project: cStock in Malawi, an eHealth tool used to improve child health. This study aims to identify lessons that can be derived from our study of cStock, with support from the literature. Methods: In this research, a literature review was first conducted to scope existing literature on LMIC eHealth projects. Secondly, a qualitative study was conducted using five Key Informant interviews of individuals directly involved in the cStock case. Thematic content analysis of these interviews was conducted to identify themes. Findings: Six major themes were identified from my view: (1) facilitators and barriers to cStock implementation; (2) facilitators and barriers related to the scale-up and sustainability of cStock; (3) the impact of the COVID-19 pandemic on cStock operations; (4) the continuing role of paper records in cStock; (5) the transition of cStock and other health systems to full electronic systems in Malawi; and (6) a related set of recommendations for improving cStock operations and future LMIC eHealth projects. Conclusions and Implications: Despite the strong commitment of the Malawi government to the cStock project, it is widely recognized in Malawi public health system that cStock does not, at this time, have a sustainable financial model. Similar practices of financial precariousness may apply to most LMIC eHealth projects with reliance on external international finance. This study contributes to the growing literature on eHealth and focuses on enabling characteristics and barriers to LMIC eHealth project implementations, scale-ups, and sustainability. Further research is needed to investigate sustainable financial models that are more likely to achieve success for future LMIC eHealth projects. / Thesis / Master of Science (MSc) / This study explored eHealth project implementation and scale-up in Low-and Middle- Income Countries (LMICs), with a specific focus on the cStock eHealth project in Malawi. The intention was to identify key lessons learned from the successful national-level scale- up of cStock in Malawi and its implications for eHealth projects in LMICs. This study contributes to the literature by examining barriers and facilitators to eHealth project implementations, scale-ups, and sustainability; in addition, evaluating the impact of the COVID-19 pandemic on eHealth projects in LMICs; and the role that paper records continue to play in LMICs. Amongst other conclusions, it was found that financial constraints in public health systems in many LMICs lead to a heavy reliance on foreign aid to finance eHealth projects which all-too-frequently lead to financially unsustainable projects; and strong national government commitment at policy, regulatory, human resource, and administrative levels are facilitators to achieving eHealth project success.

BACKGROUND: Peri-operative anticoagulation management plans reduce the risk of bleeding and thrombotic events in patients who are on anticoagulation therapy and undergoing surgical procedures. A mobile application (Thrombo-Link) has been developed as a clinical decision support tool to aid healthcare professionals in providing these management plans. Little literature exists exploring the usability of such an application. PURPOSE: The purpose of this thesis is to examine: 1) How Jakob Nielsen’s 10 Usability Heuristics can be used to identify usability shortfalls of the Thrombo-Link application to improve subsequent iterations, and 2) the role of end user testing in further identifying usability issues of the Thrombo-Link application in a clinical setting. METHODS: This study included the participation of three usability experts and five staff from the Hamilton Health Sciences peri-operative anticoagulation management clinic. Usability experts utilized Jakob Nielsen’s 10 usability heuristics to identify usability shortfalls of Thrombo-Link which were conveyed to the software developer. Iterative changes were made to the application. During the end user testing, participants were asked to use the application as they would in the clinic and completed the system usability scale (SUS) to assess the overall usability of Thrombo-Link. RESULTS: A total of 51 usability issues were identified by the heuristic evaluators and 7 usability issues were identified by the clinic staff. Clinic staff rated the application with a median answer of 5/5 on the SUS in terms of ease of use. CONCLUSIONS: Both Nielsen’s heuristics and end user testing identified usability concerns within the Thrombo-Link application which were addresses by iterative software development. This furthers our understanding of the usability of this clinical decision support tool / Thesis / Master of Science (MSc) / It is estimated that each year 10% of patients who use blood thinning therapy need to interrupt their medication to undergo surgery. This study focuses on how easy it is to use a mobile application (Thrombo-Link) that was designed to manage the process of interrupting these medications. We wanted to identify shortfalls of the application. This study used methods that made sure the application did what it was designed to do without risking patient safety. A team of usability experts did the heuristic evaluation using Jakob Nielsen’s methodology. The end user participants were staff from Hamilton General Hospital bridging clinic. Both testing approaches helped us find ways to make the application work better for the people who would be using it.

Health disparity research indicates that health illiteracy is associated with poorer health outcomes, greater risk of hospitalization, higher emergency room utilization, and increased death (Collins, Currie, Bakken, Vawdrey & Stone, 2012; Skopelja, Whipple & Richwine, 2013). Health information is increasingly being transitioned to online formats and according to Usher and Skinner (2010) the newest challenge that healthcare consumers face in taking control of their health is their ability to access, evaluate and incorporate the large amount of health information available on the Internet. Achieving a better understanding of the eHealth literacy levels of Aboriginal women and how they use technology to access health information may support better health outcomes in a variety of settings including the perinatal period which is important not only for the mother’s health, but her child’s as well. This mixed methods study explored the eHealth literacy knowledge, attitudes and skills of urban Aboriginal women in the perinatal period residing in a small city in British Columbia. A convergent parallel design was used to collect both qualitative and quantitative data from five study participants. Due to the small sample size study findings need to be interpreted with caution. The results may demonstrate that urban Aboriginal women in the perinatal period are comfortable and competent in accessing health information on the Internet. They identified the following as areas for improvement: (1) identifying if the information they retrieve is credible, (2) improving the cultural appropriateness of health information and websites, (3) improving access through continuing to build technology and search skills for Aboriginal women, and (4) supporting better access to the Internet and technology equipment for those Aboriginal women still affected by the digital divide. / Graduate

Abstract Telemedicine (TM) is a term that describes the delivery of healthcare over distances. TM has evolved along with communication technology, creating a model of TM healthcare delivery that is constantly changing. The primary advantage of TM is that it gives physicians the ability to reach out to patients remotely, providing healthcare to remote or isolated locations, thus greatly reducing the need for patient travel. The physician is the primary stakeholder of TM, but to date there is a paucity of research related to TM utilization by physicians. Specifically, it is not known whether TM is an efficient healthcare tool that allows more patients to be seen by a physician than could normally be seen face to face (F2F), hence increasing the potential volume of patient care. This study describes the adoption and utilization characteristics within a “real” medical environment (the Ontario Ministry of Long-term Health Care) by analyzing established medical practices. Using OHIP data, this study shows TM utilization trends among physicians who were responsible for a large portion of TM patient activity within their respective specialties between 2011 and 2013. By understanding TM usage by physicians, the ministry can provide programs and incentives that may increase TM adoption, thus providing more efficient healthcare to underserviced populations in Ontario. The top three specialties from 2008-2013 using TM in Ontario were found to be General and Family (G&F) practice, Internal Medicine and Psychiatry, with G&F physicians using TM primarily to increase practice volumes for addiction medicine. Within the Internal Medicine specialty, TM appears to be a tool for healthcare delivery that helps offset some F2F events. Within the specialty of Psychiatry, many TM events seemed to have been performed by psychiatrists who have smaller volumes of F2F visits compared to their peers. Trends in TM show that for some specialties and types of clinical events, TM can be used to see more patients than physicians could normally see when restricted to F2F visits only, thus reducing the number of F2F visits within some practices. / Thesis / Master of Health Sciences (MSc)

Exposure to ultraviolet (UV) radiation is the single most important risk factor for skin cancers. The incidence and severity of skin cancers are on the rise in most parts of the world including Canada. Melanoma is the most aggressive form of skin cancer with a poor prognosis. It is possible to calculate the approximate time required to develop sunburn based on the skin type of an individual and the UV index of the region of residence. A tool was constructed for this purpose using various web technologies such as PHP and JavaScript. The tool was named SUNBUC as an acronym for Sun Burn Calculator. There were two phases of the study: 1. Usability testing and 2. A controlled trial, which was designed to test the impact of the tool on the sun protection behaviour of the respondents over a period of 3 months. The null hypothesis was that tailored information and response independent information has a similar impact on sun safety behaviour as measured by the frequency of usage of sun protection methods such as sunscreen. Ethics board approval was obtained for the study. The usability of the online survey and SUNBUC was tested on five respondents using the think-aloud method and evaluated using the System Usability Scale. The evaluation showed average usability and system modifications were made according to the findings of the think-aloud study. The controlled trial design consisted of the control group with 48 respondents and intervention group with 53 respondents. Post intervention survey responses were obtained from 46(96\%) and 48(91\%) respondents belonging to the control and intervention groups respectively. Having implemented SUNBUC, findings showed no significant difference between the respondents who used the tool and the control group in short-term sun protection behaviour. However, many respondents felt that SUNBUC gave them a sense of control over their behaviour, a proximal determinant of the behaviour itself as per the Theory of Planned Behaviour. / Thesis / Master of Science (MSc)

With growing life expectancy and decreasing of fertility rates, demands of additional healthcare services is increasing day by day. This results in a rising need for additional healthcare services which leads to more medical care costs. Modern technology can play an important role to reduce the healthcare costs. In the new era of IoT, secure, fast, low energy consumption and reliable connectivity are necessary qualities to meet demands of health service. New protocols such as IEEE 802.11ax and the fifth generation of mobile broadband have a revolutionary impact over the wireless connectivity. At the same time, new technologies such as cloud computing and Close Loop Medication Management open a new horizon in the medical environment. This thesis studies different eHealth@home architectures in terms of their wireless communication technologies, data collection and data storage strategies. The functionality, benefits and gaps of current distance health monitoring architecture have been presented and discussed. Additionally, this thesis proposes solutions for the integration of new wireless technologies for massive device connectivity, low end-to-end latency, high security, Edge-Computing mechanism, Close Loop Medication Management and cloud services.

This study explored the current state of eHealth policy in Latin American and the Caribbean (LAC). It is based on a novel methodological approach to the conduct of systematic reviews of documents that are not always published in peer-reviewed journals. 33 countries were included in the study and 19 ICT and 7 eHealth policies were identified. A hybrid inductive and deductive content analysis approach was used to provide an in- depth analysis and comparison of existing national eHealth policies in LAC. The study found that there has been considerable progress in the establishment of ICT policies in the LAC region, but less so for eHealth policy specifically. The findings suggest that the establishment of a strategic framework that may guide and support decisions and choices in the development of national eHealth policies, could prove to be an essential tool in the successful implementation of eHealth in LAC.

This study explored the current state of eHealth policy in Latin American and the Caribbean (LAC). It is based on a novel methodological approach to the conduct of systematic reviews of documents that are not always published in peer-reviewed journals. 33 countries were included in the study and 19 ICT and 7 eHealth policies were identified. A hybrid inductive and deductive content analysis approach was used to provide an in- depth analysis and comparison of existing national eHealth policies in LAC. The study found that there has been considerable progress in the establishment of ICT policies in the LAC region, but less so for eHealth policy specifically. The findings suggest that the establishment of a strategic framework that may guide and support decisions and choices in the development of national eHealth policies, could prove to be an essential tool in the successful implementation of eHealth in LAC.

Introduction: Internationally, there is increasing interest in the potential of information technology to enhance the quality and efficiency of healthcare. Many countries are currently actively pursuing electronic health record implementations. However, the introduction of such systems often has significant consequences for users’ work practices and organisational functioning due to the complex processes involved in implementing and adopting new technology. Problems may be exacerbated in a national implementation context if users feel that systems are imposed and offer insufficient customisability due to a focus on achieving widespread interoperability. England has embarked on a large-scale national implementation of electronic health records. One of the procured systems was Lorenzo, which was to be built while it was being implemented. Investigating the implementation and adoption of Lorenzo is of particular interest as, in theory, the approach of “co-creating” a system in collaboration with the National Health Service (NHS) should help to increase software usability and thereby facilitate integration with work practices. I sought to understand the views and experiences of users as well as organisational consequences of introducing Lorenzo, and how these evolved over time in the complex environment of a national electronic health record implementation. Methodology and methods: I conducted a qualitative longitudinal investigation in purposefully selected secondary and community care settings which were implementing early Lorenzo functionality. I conceptualised the settings as case studies. Data collection was theory-driven in that it utilised a methodological framework, which was developed specifically for the purposes of my study and based on the existing theoretical and empirical literature. Using this framework with multi-sited ethnography helped me to examine the immediate environment in which Lorenzo was implemented without neglecting the organisational and political context in which local developments were situated. Data collection consisted of interviews with Lorenzo users and managers in case study sites; interviews with external stakeholders (including policy makers, system developers, and independent sector representatives) from outside NHS Trusts; non-participant observation of staff meetings and use of the technology; as well as a combination of field notes, documents pertaining to Trusts and wider political developments, and press statements. Data collection and thematic analysis were informed by a sociotechnical Actor-Network Theory-based approach highlighting the interrelated nature of technical and social dimensions. The study also drew on other related theoretical frameworks that helped to address some of Actor-Network Theory’s theoretical and practical shortcomings. Most helpful in this respect were Strong Structuration Theory, the Social Shaping of Technology, and the Theory of the Diffusion of Innovations (theoretically); and multi-sited ethnography and case studies (practically). I employed inductive and deductive analytical techniques utilising thematic tables for organising and interpreting the data. Individual case studies were analysed first in order to examine local dynamics, before cross-case comparisons were made and findings were integrated with data obtained from outside case study sites. Results: I collected data between 2009 and 2011 in three case study sites. The complete dataset comprised interview data from a total of 66 different participants within Trusts, 14 interviews with stakeholders from outside case study sites, 38.5 hours of non-participant observation, 149 pages of press statements, 31 pages of field notes, and a range of national and local Trust documents. The three sites differed in demographics and local implementation strategies, and hence presented diverse stories of sociotechnical change unfolding over time within their complex individual contexts. However, there were also similarities, not least the fact that all were implementing the same system and that they were operating within constantly evolving political and economic contexts. Users found it difficult to integrate Lorenzo with their everyday work practices as the software was perceived to be not fit-for-purpose. Over time, these difficulties attenuated to some extent, particularly in the smaller-scale deployments in sites that had invested significant time and resources to adapt the software to fit with their everyday practices. Lorenzo implementation also had significant consequences for organisational functioning, which was often hampered by local restrictions in software customisability associated with national arrangements. Conclusion: I have developed a theoretically informed methodological framework and applied this to explore sociotechnical processes involved in the implementation and adoption of Lorenzo. In doing so, I identified potentially transferable theoretical insights into local and national developments over time and based on these proposed mechanisms involved in the implementation and adoption process. Overall, my findings help to explain why the adoption of Lorenzo was much slower and on a smaller scale than originally anticipated. The interplay between social (political, individual and organisational) and technical factors was central to implementation progress. At the root of many problems encountered were difficulties with integrating systems with work practices of users and more general organisational functioning. In relation to Lorenzo, co-creating national software with strong user involvement was hampered due to different requirements in individual settings and wider, political and economic constraints. Based on the English experience, there may be some important transferable lessons for similar ventures in other countries. Most importantly, national implementations need to build on a solid basis of local technology adoption by allocating sufficient time for individual users and organisations to adjust to the complex changes that often accompany such service redesign initiatives.

L'introduction des technologies de l'information et de la communication (TIC) dans la relation de soins est une déclinaison d'un mouvement plus global, tendant à la construction d'une véritable société de l'information. Si le secteur de la santé n'est pas épargné par ces usages nouveaux, il mérite néanmoins une étude particulière tant le colloque dit singulier, entre le médecin et son patient, est empreint de singularité. La télémédecine, en tant que pratique médicale à distance, s'illustre par son ancienneté, et la nouveauté de son cadre normatif. D'abord, offrant une mutation spatiale et temporelle de l'exercice médical, les TIC déplacent les frontières traditionnelles, et celles notamment reconnues à l'auteur et à la finalité de l'acte médical. Le colloque devient pluriel et dématérialisé. Ensuite, les enjeux du recours aux TIC, nouvel écran technique, ont rendu impérieux l'intervention du droit, afin qu'il encadre et en régule l'usage. Le droit de la relation de soins recourant aux TIC est protéiforme. Les droits et devoirs des médecins et des patients s'appliquent invariablement à cette nouvelle forme de pratique médicale. Mais, le législateur a tenté d'étoffer ce cadre en initiant des règles dédiées, parcellaires et lacunaires. Le recours aux autres branches du droit est nécessaire au dessein d'un encadrement global. Il démontre pourtant son insuffisance ou son inadaptation à une activité si singulière. / The introduction of information and communication technologies (ICT) in the caring relationship is part of a wider movement, aiming at building a real society of information. Although public health is not spared from those new customs, it nevertheless deserves its own specific study, given the singularity imprinted by patient-doctor relationships. Telemedicine, as a distant medical practice, is characterized by its seniority and the novelty of its normative frame. First of all, offering a spatio-temporal mutation of the medical practice, TIC shift traditional boundaries, including those recognized to the author and finality of the medical act. The doctor-patient bond becomes plural and dematerialized. Then, challenges implied by the resort to TIC, this new technical screen, made very imperious the intervention of the law to supervise and control its use. Caring relationship law resorting to TIC is protean. Doctors and patients' rights and duties invariably apply to this new form of medical practice. However, the lawmaker tried to fill this frame out by initiating dedicated rules, yet remaining piecemeal and lacunar. Resorting to the other fields of law is needed with view to a wide supervision. It however demonstrates its failure or unsuitability for such singular activity.