Ces travaux de thèse présentent une approche de pharmaco-épidémiologie explorant l'exposition médicamenteuse chez des patients atteints de lymphome tout au long de leur parcours de soin. L'utilisation des données du Système National d'Information Inter-régimes de l'Assurance Maladie (SNIIRAM) nous a permis de quantifier cette exposition médicamenteuse et de déterminer les facteurs associés dans le contexte de la vie réelle. Les travaux de recherche réalisés au cours de cette thèse répondaient à 3 objectifs. Dans un premier objectif, nous avons souhaité valider l'utilisation du SNIIRAM à des fins de recherche pour améliorer la robustesse des futures études menées sur le lymphome. Après avoir défini plusieurs algorithmes d'identification des cas incidents de lymphome, nous avons testé leur validité par confrontation aux données cliniques exhaustives du Registre des cancers du Tarn. Les paramètres de performance obtenus permettent de considérer les données disponibles dans le SNIIRAM comme un outil puissant pour mener des études pharmaco-épidémiologiques ou médico-économiques sur le Lymphome. Le second objectif était d'explorer l'existence d'une surconsommation de médicaments psychotropes au cours de la phase active de traitement par rapport à une population témoin, sous l'hypothèse d'une initiation accrue de ces médicaments pour pallier les complications psychologiques associées à la prise en charge du Lymphome. Par ailleurs, la chronicisation fréquemment observée de ce type de consommation peut conduire à terme à des complications potentiellement évitables. Pour répondre à cet objectif, nous avons réalisé une étude selon une approche " new-user design ", à partir d'une cohorte de patients incidents de lymphome identifiés dans les données du SNIIRAM à l'échelon régional. Nous avons observé un taux d'initiation supérieur au taux observé en population générale ou chez des patients atteints d'autres pathologies mettant en jeu le pronostic vital (infarctus du myocarde). En fonction de la classe thérapeutique étudiée, 20 à plus de 50% des patients restaient exposés de façon inappropriée (au-delà des recommandations) à ces médicaments. Le troisième objectif a donc été d'explorer les déterminants associés à une utilisation prolongée de médicaments psychotropes dans la phase de l'après-cancer à partir des données de l'Echantillon généraliste des bénéficiaires (EGB). [...] / This thesis presents a pharmacoepidemiology approach to describe drug utilization in lymphomas during their whole care pathway. The use of the French claims database (Système National d'Informations Inter-Régimes de l'Assurance Maladie (SNIIRAM)) allows to exhaustively quantify this drug utilization in real life conditions. This thesis consists of three mains objectives. First, we aimed to develop validated algorithms for the identification of incident cases of lymphoma. For the validation, we used data from a regional Cancer Registry as the gold standard. The purpose of this validation study was to enhance validity of future studies conducted on lymphomas in the SNIIRAM database. The results of this study associated to strengths of this database demonstrate that this approach is of great interest to conduct pharmacoepidemiological or medico-economic studies in lymphomas. Second, we aimed to estimate the incidence of use of psychotropic drugs during the active treatment phase of lymphoma in comparison with control groups. Indeed, the increased probability of developing anxio-depressive disorders after diagnosis could lead to an increased initiation of psychotropic drugs and a potential inappropriate chronic use of these drugs after initiation. Such inappropriate chronic use can unnecessarily expose patients to adverse event. For this aim, we conducted a new-user cohort study using data from the SNIIRAM database. The results of this study revealed that the initiation rate of these drugs is higher than in the general population or for life-threatening diseases such as myocardial infarction. Moreover, we observed an inappropriate prolonged use for a significant fraction of patients (20% to more than 50% according to therapeutic class). On the basis of these findings, the third objective was to identify factors associated with prolonged use of these drugs during survivorship. This study was conducted using data from the General Sample of Beneficiaries (EGB). [...]

The use of electronic health records (EHR) has the potential to improve relationships between physicians and patients and significantly improve care delivery. The purpose of this study was to analyze the relationships between hospital attributes and EHR implementation. The research design for this study was the cross-sectional approach. Secondary data from the Health Information and Management Systems Society (HIMSS) Analytics Database was utilized (n = 169) in a correlational crosssectional research design. Normalization Process Theory (NPT) and implementation theory were the theoretical underpinnings used in this study. Multiple linear regressions results showed statistically significant relationships between the 4 independent variables (region, ownership status, number of staffed beds [size], and organizational control) and the outcomes for the dependent variables of EHR software application attributes (Clinical Decision Support Systems (CDSS) components), EHR software application attributes (major systems), and successful implementation of Meaningful Use (MU) (p = .001). A statistically significant relationship (p = .001) was also found between the 2 independent variables (EHR software application attributes [CDSS components] and EHR software application attributes [major systems]) and the outcome of successful implementation of MU when combined. This evidence should provide policy makers and health practitioners support for their attempts to implement EHR systems to result in positive Meaningful Use which has been shown to be more cost effective and result in better quality of care for patients.The potential social change is improved medication prescribing and administration for hospitals and, lower cost and better quality of care for patients.

Workflow issues related to adoption of the electronic health record (EHR) has led to unsafe workarounds, decreased productivity, inefficient clinical documentation and slow rates of EHR adoption. The problem addressed in this quality improvement project was nurses' lack of knowledge about workflow changes due to EHR adoption. The purpose of this project was to identify changes in workflow and to develop an educational module to communicate the changes. This project was guided by both the ADDIE model (analysis, design, development, implementation, and evaluation) and the diffusion of innovations theory. Five stages were involved: process mapping, cognitive walkthrough, eLearning module development, pilot study, and evaluation. The process maps and cognitive walkthrough revealed significant workflow changes particularly in clinical practice guidelines, emergency department treatment plan, and the interdisciplinary care plan. The eLearning module was developed to describe workflow changes using gamification, scenario-based learning, and EHR simulation. The 14-item course evaluation included a 6-point Likert scale and closed- and open-ended questions. A purposive sample of nurses (N = 30) from the emergency department and inpatient care areas were invited to complete the eLearning module and course evaluation. Data were collected until saturation was achieved (n = 15). Descriptive statistics revealed the participants' positive learning experience. This quality improvement project is expected to contribute to positive social change by facilitating the effective use of the new EHR which can improve the quality of patient care, promote patient safety, reduce healthcare costs, and improve patient outcomes.

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

Community Health Centers (CHCs) are the nation's primary care safety-net for vulnerable populations, including racial/ethnic minorities, migrant workers and the uninsured. Women from these populations contribute disproportionately to cervical cancer morbidity and mortality, largely due to underutilization of Pap smear screening. The purpose of this cross-sectional study was to identify factors that may be related to Pap smear screening compliance among a large cohort of women seen at 10 Community Health Centers in Florida. Building upon an ecologic framework, this research went beyond patient-level risk factors, which are generally well-known, and explored provider and organizational variables that may also be associated with Pap smear screening compliance in this population. Ten CHCs in Florida met study inclusion criteria of having at least four complete years of claims and patient registration data stored in an Electronic Health Record (HER) data system maintained at HCN. EHR data were merged with provider gender obtained from a credentialing database and with data from a short organizational survey administered to the Medical Directors of the CHCs. Descriptive statistics, chi-squared analysis, and multiple logistic regression were used to examine Pap smear screening rates for women (n=71,234) in relation to a variety of patient, provider and organizational variables. Younger, Hispanic and insured women were most likely to have had a screening in the past three years compared to older, white non- Hispanic and uninsured women. Among providers, patients who received care from female providers generally had higher Pap smear compliance rates, but these findings differed by patient insurance and race/ethnicity group. Organizational factors that appeared to be associated with higher Pap compliance rates included diffusion of an EHR system, implementation of "Care Model Principals", and having recently implemented a Pap smear screening process improvement project. Results demonstrated that multi-level factors, operating on the patient, provider and organizational levels, contribute to Pap smear compliance among women seen at CHCs. Results suggested that improving screening compliance within this population of women requires interventions that are ecologic in scope, incorporate targeted education to high-risk women and providers, and include organizational strategies that can optimize care delivery at point-of-care.

Our ultimate goal as obstetric and neonatal care providers is to improve care for mothers and their babies. Continuous quality improvement (CQI) involves iterative cycles of practice change and audit of ongoing clinical care identifying practices that are associated with good outcomes. A vital prerequisite to this evidence based medicine is data collection. In Canada, much of the country is covered by separate fragmented silos known as regional reproductive care databases or perinatal health programs. A more centralized system which includes collaborative efforts is required. Moving in this direction would serve many purposes: efficiency, economy in the setting of limited resources and shrinking budgets and lastly, interaction among data collection agencies. This interaction may facilitate translation and transfer of knowledge to care-givers and patients. There are however many barriers towards such collaborative efforts including privacy, ownership and the standardization of both digital technologies and semantics. After thoroughly examining the current existing perinatal data collection among Perinatal Health Programs (PHPs), and the Canadian Perinatal Network (CPN) database, it was evident that there is little standardization of definitions. This serves as one of the most important barriers towards data sharing. To communicate effectively and share data, researchers and clinicians alike must construct a common perinatal language. Communicative tools and programs such as SNOMED CT® offer a potential solution, but still require much work due to their infancy. A standardized perinatal language would not only lay the definitional foundation in women’s health and obstetrics but also serve as a major contribution towards a universal electronic health record.

<p>This dissertation aimed to investigate the use of electronic nursing documentation as a strategy to improve the quality of care provided to hospitalized patients. The literature to support the use of electronic nursing documentation on the quality of care delivered to patients is limited to date. Additionally, the literature describing the use of information for the delivery of care on paper-based nursing documentation is limited. This dissertation reviews the current literature, investigated the knowledge needed for nurses to know their patients and established categories of nurses' information needs as preliminary work to be able to descriptively compare the use of paper with electronic nursing documentation on inpatient care units within a hospital setting. The main study conducted for this investigation used a mixed-methods multiple case study design, to describe the processes of information use on two inpatient care units, while first using paper and subsequently electronic nursing documentation. Findings revealed the importance of the categories of nurses' information needs for both cases in addition to the use of verbal, paper-based and electronic information sources for the collection, communication and temporary storage of information needs. Additionally, the conversion to electronic nursing documentation introduced new challenges related to three quality metrics: efficiency, timeliness and safety. Recommendations are provided for further evaluation of electronic health records with additional consideration for appropriate hardware devices in the context of the care environment.</p> / Dissertation

In health services, it is a necessity to keep the records of the patients. Although paper-based records are commonly used for this aim, they are not as convenient as computerized records. Therefore, many of the health facilities have recently started keeping patients&rsquo / health records in electronic databases. However, new questions about confidentiality and privacy of these records were raised with this new system.This study aims to investigate the opinions and attitudes of the people who use the health services of Turkey about the privacy and confidentiality of health information in electronic environment. In the survey, there are 596 participants from 64 different cities in six geographical regions of Turkey. The findings show that people feel comfortable about computer usage in health-care but they are concerned about the privacy and confidentiality of their information and also they are not sure if their medical information is safe and secure now. Moreover, they are mostly unaware about current regulations related to information privacy in Turkey. The study also shows that people trust in their doctors, health researchers in universities, pharmacist, nurses and other hospital staff but do not trust in insurance companies, government, private sector health researchers, information technology specialists and government health researchers for the privacy of their medical records.

The implementation of planned organizational change is ultimately a communication-related phenomenon, and as such, it is imperative that organizational communication scholars examine the interactions surrounding EHR implementation and understand how users (e.g. healthcare practitioners) utilize, evaluate, and deliberate this new technological innovation. Previous research on planned organizational change has called for researchers to adopt a more dynamic perspective that emphasizes the active agency of organizational members throughout implementation processes and focuses on informal implementers and change reinvention (work-arounds) as individuals actively reinterpret and personalize their work roles during implementation socialization. This dissertation seeks to fill this gap in research by demonstrating how communication between doctors, nurses, and other health professionals affects the adoption, maintenance, alternation, modification, or rejection of EHR systems within health care organizations. To delve into these inquiries and examine the intersecting domains of medical informatics and organizational communication research, this dissertation proceeds in the following manner: First, a literature review, capitalizing on Laurie Lewis’s work in planned organizational change and social constructionist views of technology use in organizations, outlines the assumptions that undergird this research. Next, this dissertation builds a model that predicts the communicative and structural antecedents of the study outcome variables, which include 1) organizational resistance to EHR implementation, 2) employees’ perception of EHR implementation success, 3) levels of change reinvention—or work-arounds—due to change initiatives and activities, and 4) employees’ perceptions of the quality of the organizational communication surrounding the change. Hypotheses guiding the model specification are provided and are followed by a description of the empirical methods and procedures that were utilized to explore the variable relationships. Results of the SEM model suggest that work-arounds could play a mediating role governing the relationship between informal social influence and the outcome variables in the study. In addition, one-way ANOVAs and multiple regression analyses reveal that physicians are the most resistant to EHR implementation and perceived change communication quality positively predicts perceived EHR implementation success and perceived relative advantage of EHR and negatively predicts employee resistance. A discussion of the expected and unexpected results is offered in addition to study limitation and future directions. / text

Η μηχανοργάνωση των φορέων υγείας αποτελεί προαπαιτούμενο για τη βελτίωση των παρεχόμενων υπηρεσιών τους ως προς τους πολίτες. Αν και η διεργασία έχει καθυστερήσει σημαντικά, φαίνεται πως οι εμπλεκόμενοι έχουν αντιληφθεί τη σπουδαιότητα της και πλέον ήδη βρίσκονται σε εξέλιξη προγράμματα προς αυτή την κατεύθυνση. Η ορθοπαιδική κλινική του ΠΓΝΠ, αποτελεί υπόδειγμα στο συγκεκριμένο τομέα καθώς ήδη από δεκαετίας έχει ηλεκτρονικό αρχείο με βασικά στοιχεία των ασθενών που νοσηλεύτηκαν, ενώ το 2005 πήγε ένα βήμα παραπέρα και επέκτεινε τη μηχανοργάνωση της με ηλεκτρονικό φάκελο υγείας ασθενή, εντάσοντας και τις απεικονιστικές εξετάσεις. Στο παρόν κείμενο στην εισαγωγή γίνεται μια ανάλυση της υπάρχουσας κατάστασης και μια λεπτομερής περιγραφή των προγραμμάτων που βρίσκονται σε εξέλιξη σχετικά με το θέμα. Δίνεται μια εξήγηση για την υστέρηση που έχει παρουσιαστεί και τα προβλήματα που αντιμετωπίζουν ανάλογα εγχειρήματα. Στην ενότητα 4 περιγράφεται σε γενικές γραμμές η εφαρμογή (λογισμικό) που εγκαταστάθηκε στην ορθοπαιδική κλινική και πως αυτή μηχανογραφεί της λειτουργικές διαδικασίες που ακολουθούνται στην καθημερινότητα του τμήματος. Στην επόμενη ενότητα η αναφορά εστιάζει περισσότερο στο “μικρόκοσμο” της κλινικής. Μιλάει με στατιστικά στοιχεία για το προσφερόμενο έργο της και ουσιαστικά αναλύει τον τρόπο με τον οποίο έγνε η εφαρμογή της μηχανοργάνωσης. Πώς ξεπεράστηκαν προβλήματα, τι χειρισμοί έγιναν με το προσωπικό, τι διαρθωτικές αλλαγές έγιναν ώστε να δημιουργηθεί ένα νέο τμήμα που ανέλαβε να κάνει το data entry. Η συνέχεια είναι με τις προοπτικές εξέλιξες οι οποίες χάρη σε μια θετική συγκυρία φαντάζουν εξαιρετικά ευοίωνες και στο τέλος παραθέτονται κάποια τεχνικά παραρτήματα που αφορούν περισσότερο το προσωπικό της κλινικής κι έχουν στόχο τη μετάδοση γνώσεων που θα βοηθήσουν στην εύρυθμη λειτουργία. / Computerization of health organizations consists precondition for the improvement of provided health services to citizens. Despite the process has an important delay, it seems the concerned parts are aware of the importance and projects aiming on this direction running already. The clinic of Orthopaedics at University Hospital of Patras, insists a positive sample in this sector. Since 90’s keeps a basic electronic database of patients’ data and in 2005 stepped forward adding health records and imaging platings (PAKS). Present thesis makes an analysis of present status and a description of relative projects in progress. An explanation for the hysteresis is given and solutions for past resolved problems. In chapter 4 presented the installed software in the clinic of Orthopaedics and how it is engaged with the procedures taking place in day life. In the next chapter the present thesis focuses on the clinic. It speaks in the language of statistics for the offered work towards the society and analysis the steps followed for the project of computerization. Finishing with the potential for evolution which seems to be very high thanks to a trend.