Class of 2013 Abstract / Specific Aims: To examine the relationship between hospital readmission rates and responses to a medication adherence questionnaire (Morisky) in patients with congestive heart failure (CHF). Methods: The Morisky questionnaire, assessing medication adherence, was administered to all CHF patients admitted from September 15, 2012 to March 7, 2013. Information collected from the electronic medical record (EMR) for all patients with complete Morisky questionnaires included: age, sex, ethnicity, insurance, height, weight, marital status, tobacco use, alcohol use, number of home medications, all-cause and CHF admission in the previous 365 days from when the questionnaire was administered as well as the following events/disease states: myocardial infarction, hypertension, atrial fibrillation, stroke, diabetes mellitus, peripheral vascular disease, chronic obstructive pulmonary disease, congestive heart disease and chronic kidney disease. Main Results: Of the 120 patients enrolled, 52% scored 1-5 on the Morisky questionnaire indicating some problem with medication adherence while 48% scored 0 (no problems). There was no correlation between the Morisky score and age (95% CI: -3.3-5.7), number of medications (95% CI: -0.26, 2.85), or number of comorbidities (95% CI: -1.02,0.03). The Morisky questionnaire was not predictive of all cause readmissions (95% CI: 0.35, 2.01) p = 0.691). For CHF readmissions the Morisky score was not significant (95% CI: 0.6, 4.11, p=0.358) but the confidence interval suggests a trend. Conclusion: There is no correlation between Morisky scores, age, comorbidities, and medication number. Readmission rates were not predicted by Morisky scores; with more participants a trend may be detected for CHF readmissions.

Electronic medical records (EMR) and computerized provider order entry (CPOE) are recognized as a means to improve quality of care and patient safety. This research examines factors that contribute to clinician acceptance of an EMR implemented in a pediatric hospital system and applies this knowledge to improve implementation methods to ensure they foster acceptance. A framework for User-Centered Implementation (UCI) was developed based on previous EMR and CPOE, technology acceptance, user-centered design, and change management research. The UCI framework identifies tools from change management and user-centered design and links them to the systems development lifecycle stage(s) at which they can be applied to achieve improved user acceptance. Next, a study examined clinician EMR acceptance in a pediatric hospital system at various points during their EMR implementation which employed a UCI-based methodology. Surveys before and after implementation of each phase examined physician, nurse, and other staff perceptions about the systems usefulness (performance expectancy (PE)) and ease of use (effort expectancy (EE)). Results indicate users had positive perceptions of system ease of use (EE) after implementation. Post-implementation PE ratings were neutral or positive for most users. Pre- and post-implementation regression models indicate the factors that influence PE change over time. Compatibility with clinician work practices was important both before and after implementation. Before implementation, users who perceived a greater need for the system and felt their needs were represented during design had higher expectations of system usefulness. After implementation, system characteristics including how well it supports clinical decision making and how easy it is to use influenced PE. Support provided by super users positively influenced both PE and EE after implementation. Based on these findings, guidelines for using UCI to improve clinician acceptance of EMR are presented. Designing EMR systems that are usable within the clinical work context enables clinicians to focus on the patient, rather than the system. Accomplishing this in practice is difficult given the complexity of EMRs and the dynamic clinical processes they support. This studys results indicate the UCI framework can be effectively applied to EMR implementations to improve the usability, utility, and, consequently, acceptance of these systems.

我國全民健康保險制度自2004年1月1日開始使用健保IC卡後，醫療資訊電子化的趨勢，某種意義上來說，已經如凱撒（Gaius Julius Caesar）渡過盧比孔河（Crossing the Ribucon）時所說：「骰子已經投下（the die is cast）」一般，只能前進不能後退了！ 時至今日，電腦、網路連線、憑證簽章已經成為任何一間醫療院所從事醫療行為時的開門七件事之一，民眾用健保IC掛號、醫師用電腦下診斷作病歷、行政人員用健保VPN申報費用等，皆成為醫療實務中的標準模式。而我國衛生署也信心滿滿地希望能於2011年達到全國80%醫院實施電子病歷、60%醫院可為院際交換互動之目標。在此「全民電子病歷」旋將施行之當下，相關隱私權之配套對於病人之保障是否足夠，即成為該政策是否受到國人支持之關鍵所在。 本研究透過整理衛生署自2000年迄今所有與電子病歷相關之專案計畫，以及與電子病歷領域，產、官、學界共9位受訪者進行深度訪談後發現，我國現行電子病歷政策推廣有架構、標準、法制、補助、動機等五大問題，其中關於法制規範及隱私保障不足所造成的民眾疑慮與醫事人員躊躇，已成為電子病歷發展上的一大阻礙，而其中計畫推行的電子病歷索引交互中心，更可能對於病人資訊隱私權產生重大危害與影響。另一方面，若回頭省視司法院大法官釋字第603號解釋，大法官們其實已對涵蓋電子病歷等個人資料之資訊隱私權，有過相當明確的闡釋。其所強調「個人自主控制其個人資料之資訊隱私權」，若能配合2010年5月26日修正通過但尚未施行之個人資料保護法，並非不能為電子病歷提供一個基本、框架式的法律基礎。 在此前提之下，本文提出「電子病歷自主控制機制」之概念，主張在現行憲法資訊隱私權之精神下，應該讓病人在充分瞭解到其權益後，得以選擇「是否將病歷電子化」、「電子病歷儲存場所」、「是否放於交換區」、「是否留存索引紀錄」、「是否允目的外利用」，並能透過管道隨時查詢其「電子病歷使用紀錄」。本文並認為，藉由「推力理論（Nudge）」中「自動加入（Opt-in）」與「主動加入（Opt-out）」等「預設值（Default）」概念之運用，資訊科技中「隱私偏好選項（Privacy Preference）」與「電子病歷使用紀錄明細」等系統之設立與使用，以及國際相關隱私及安全規範之借鏡，與我國健保IC卡推行之在地經驗，或許能夠解決論者對於電子病歷自主控制機制，在參與度、決定能力、行政成本、法規及技術架構、多元價值上的各項疑慮與爭論，並進而證明該構想之初步可行性。 / After implementation of the National Health Insurance (NHI) IC Card on January 1, 2004, the trend of e-health, including enforcing a national electronic medical record (EMR) system in Taiwan, is reminiscent of Julius Caesar’s words when he crossed the Rubicon, “The die is cast.” The return point has been passed; there is no return. Nowadays in Taiwan it has become routine in hospitals and clinics for medical practitioners to use a digital authentication or signature transmitted via a computer scan of an NHI IC card to register patients for diagnosis and treatment, and for administrtive staff using Virtual Private Network (VPN) to file fee claims. Furthermore, the Taiwan Department of Health has announced its implementation of the EMR system and has pledged that, in 2011, 80 percent of hospitals and clinics will start to use a more comprehensive EMR system and 60 percent of hospitals will be able to exchange EMRs. However, while Taiwan’s government is very proud and eager to enforce the EMR system, an increasing number of people doubt that adequate regulations have been put in place to protect against the violation of patients’ information privacy rights. This paper first reviews all former DOH projects related to EMRs, and interviews nine industry, government, and academic professionals who have EMR experience. It next argues that the current laws and regulations in Taiwan cannot provide sufficient protection of patients’ privacy rights, especially with regard to information privacy and autonomy. This is a cause for concern for patients and practitioners who are leery of further EMR implementation or development. This paper proposes a controlling mechanism for patients’ autonomy that will empower patients to determine if they want to electronize their medical records, where they will store their EMRs, and if it is in their best interests to set up an index and allow the transmission of additional EMRs. Moreover, patients will have unrestricted access to a log of all users and uses made of their EMRs and be able to set up their own privacy preferences with opt-in and opt-out choices. This paper concludes that the controlling mechanism for patients’ autonomy will solve the current concerns about the implemenation of a national EMR system and improve patients’ ability to enforce their information privacy and information autonomy rights.