L’objet principal de cette thèse concerne le Dossier Patient Informatisé (DPI) dans les hôpitaux, et plus particulièrement les difficultés d’usage après la phase d’implémentation. Notre démarche visait à concevoir, à partir des connaissances académiques en Système d’Information, une méthode permettant aux acteurs de terrain d’agir sur une problématique spécifique. Concrètement nous cherchions à savoir comment améliorer les situations de « misfit », c’est à dire les situations dans lesquelles les professionnels de santé considèrent l’usage du DPI comme inadapté à leur métier. Pour ce faire, nous avons cherché à comprendre le bilan mitigé du DPI dans la littérature en utilisant les travaux d’Adler & Borys (1996) sur le caractère dual de la formalisation du travail induite par la technologie (habilitante ou coercitive). Une technologie habilitante permet de positionner un utilisateur comme source de solutions, alors qu’une technologie coercitive tend à le considérer comme source de problèmes. Dans le premier manuscrit portant sur l’autonomie des professionnels de santé face au système d’information hospitalier, nous avons conclu sur la nécessité d’une formalisation de type habilitante pour améliorer l’usage du DPI. Dans le deuxième manuscrit, nous avons montré que dans les exemples d’expériences négatives du Dossier Patient Informatisé rapportés dans la littérature, il était possible de mettre en évidence les différents aspects d’une formalisation coercitive. Pour argumenter sur le caractère dual de la formalisation du travail induite par le DPI, nous avons rapporté dans le troisième manuscrit une étude empirique illustrative. Nos données montrent que pour un même DPI, dans un même hôpital, il peut exister des îlots de formalisation habilitante. En sortant du seul domaine d’application de la santé, nous avons approfondi les travaux sur la conceptualisation du misfit entre processus d’affaires et Système d’Entreprise (SE) de Strong & Volkoff de 2010, en utilisant les concepts d’affordance et d’actualisation d’affordance utilisés par les mêmes auteurs en 2013 et 2014. Le quatrième manuscrit présente donc un modèle original permettant d’analyser l’usage des technologies de l’information pour un processus d’affaires donné sous la forme d’une combinaison d’actualisations, de non-actualisation ou d’actualisations partielles de multiples affordances du système d’entreprise par de multiples acteurs. Dans une perspective réaliste critique, le misfit est alors la perception par un individu ou un groupe d’individus que cette combinaison ne répond pas à l’ensemble ou à une partie des objectifs du processus de façon satisfaisante. Nous rapportons ensuite comment, dans le cadre d’une recherche-action, nous avons utilisé ce modèle pour améliorer l’usage d’un DPI en post-implémentation dans un hôpital. L’analyse d’une situation de misfit selon notre méthode permet une recombinaison, en recherchant une suite cohérente d’ajustements techniques et organisationnels acceptables pour toutes les parties prenantes et dont l’agencement permet bien la disparition du misfit initial, mais aussi de l’ensemble des misfits révélés pendant l’analyse. Cette recombinaison aboutit alors à une formalisation du travail présentant toutes les caractéristiques d’une formalisation habilitante.La discussion de la thèse aborde les conditions du succès de la méthode, le choix des situations sur lesquelles l’appliquer et les perspectives de recherche qui en découlent. / The main focus of this thesis is the Electronic Patient Record (EPR) in hospitals, and more particularly the difficulties of use after the implementation phase. Our approach aimed to design, with the academic knowledge of Information Systems, a method allowing field actors to act on this specific issue. In concrete terms, we were looking for ways to improve "misfit" situations, i.e. situations in which health professionals consider the use of EPR to be unsuitable for their profession. To do this, we sought to understand the mixed record of EPR use reported in the professional literature, by using the dual nature (enabling or coercive) of technology-induced work formalization (Adler & Borys, 1996). Enabling technology allows a user to be positioned as a source of solutions, while coercive technology tends to consider them as a source of problems. In the first manuscript on the autonomy of health professionals in relation to the hospital information system, we concluded that an enabling formalization is needed to improve the use of EPR. In the second manuscript, we showed that in the examples of negative experiences of the EPR reported in the literature, it was possible to highlight the different aspects of coercive formalization. To argue on the dual nature of the formalization of work induced by EPR, we have reported in the third manuscript an illustrative empirical study. Our data show that for the same EPR, in the same hospital, there may be islets of enabling formalization.Moving beyond the health field of application alone, we have further developed Strong & Volkoff's 2010 conceptualization of the misfit between business process and Enterprise System (ES), using the concepts of affordance and affordance-actualization used by the same authors in 2013 and 2014.The fourth manuscript therefore presents an original model for analyzing the use of information technology for a given business process in the form of a combination of actualizations, non-actualizations or partial actualizations of multiple affordances of the enterprise system by multiple actors. From a critical realistic perspective, misfit is then the perception by an individual or group of individuals that this combination does not satisfactorily meet all or some of the objectives of the process.We then report on how we used this model to improve the use of EPR in post-implementation in an action research project. The analysis of a misfit situation according to our method allows a recombination, by seeking a coherent sequence of technical and organizational adjustments acceptable to all stakeholders and whose arrangement allows the disappearance of the initial misfit, but also of all the misfits revealed during the analysis. This recombination then leads to a formalization of the work that has all the characteristics of an enabling formalization.The discussion of the thesis addresses the conditions for the success of the method, the choice of situations on which to apply it and the resulting research perspectives.

This work presents a boarding on the use of contextual information in a model of access control to electronic patient record (EPR). The EPR registers information on the health of the patient and the assistance given it, and has legal, secret and scientific character, being able to also include administrative and financial contents related the carried through procedures or treatments. In summary, can be said that the EPR keeps to the documents on the state of health and the cares received for an individual throughout its life. However, the availability of clinical information in computer networks raises questionings on the privacy of the patients and the integrity and confidentiality of the data. The access control is a point key to keep such requirements. The main objective in the development of this modelof access control is to provide different forms of access to information in a hospital environment, propitiating the adequacy with the pertinent legislation. To boarding proposal in this work allows to the application of politics and more specific rules of access, adding more functionality to the systems of access control. The focus of quarrel of this work deals with the use of medical information in the scope of the University Hospital of Santa Maria, and aims at to the integration of the model with modules in development in the data processing center of the institution. / Este trabalho apresenta uma abordagem sobre a utilização de informações contextuais em um modelo de controle de acesso a informações de prontuários eletrônicos de paciente (PEP). O PEP registra informações sobre a saúde do paciente e a assistência a ele prestada, e tem caráter legal, sigiloso e científico, podendo incluir também conteúdos administrativos e financeiros relacionados a procedimentos ou tratamentos realizados. Resumidamente, pode-se dizer que o PEP guarda os documentos sobre o estado de saúde e os cuidados recebidos por um indivíduo ao longo da sua vida. Entretanto, a disponibilização de informações clínicas em redes de computadores levanta questionamentos sobre a privacidade dos pacientes e a integridade e confidencialidade dos dados. O controle de acesso é um ponto chave para manter tais requisitos. O principal objetivo no desenvolvimento deste modelo de controle de acesso é prover diferentes formas de acesso a informações em um ambiente hospitalar, propiciando a adequação com a legislação pertinente. A abordagem proposta neste trabalho permite a aplicação de políticas e regras de acesso mais específicas, agregando mais funcionalidade aos sistemas de controle de acesso. O foco de discussão desta dissertação trata da utilização de informações médicas no âmbito do Hospital Universitário de Santa Maria, e visa à integração do modelo com módulos em desenvolvimento no centro de processamento de dados da instituição.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2018-04-02T18:28:39Z No. of bitstreams: 1 Mara Michele Nunes de Moura.pdf: 1541991 bytes, checksum: b4c601550062a21e3fcb52847facead8 (MD5) / Made available in DSpace on 2018-04-02T18:28:39Z (GMT). No. of bitstreams: 1 Mara Michele Nunes de Moura.pdf: 1541991 bytes, checksum: b4c601550062a21e3fcb52847facead8 (MD5) Previous issue date: 2018-02-27 / This research aims to analyze the main factors that affect the adoption of technological innovation in health information systems in a Hospital Unit and the reflexes of this adoption for professionals involved in the prescription and administration of medication, influencing safety indicators of the patient. The PEP is characterized as an instrument of access to the medical information necessary for both the professional and the patient and allows the integration of information inserted in real time by multidisciplinary professionals involved in the provision of patient care, improving communication and quality during patient care . Despite the advantages offered by the PEP, there are still many challenges to be faced, such as the high cost for adequate computerization of Hospital Units and the resistance of health professionals to join the system. The research is a case study, whose approach to research was qualitative and quantitative, exploratory and descriptive. A total of 134 handwritten medical prescriptions and 268 electronic medical prescriptions were analyzed, both analyzed in 30 consecutive days, considering the analysis period determined for phase of the study. Of the handwritten prescriptions 34% had erasures and 89,1% presented illegibility in at least on of the prescription items. / Esta pesquisa tem por objetivo analisar os principais fatores que afetam a adoção da inovação tecnológica em sistemas de informações na área de saúde em uma Unidade Hospitalar e os reflexos dessa adoção para os profissionais envolvidos no processo de prescrição e administração de medicação, influenciando indicadores de segurança do paciente. O PEP se caracteriza como um instrumento de acesso ás informações médicas necessárias tanto ao profissional quanto ao paciente e possibilita a integração de informações inseridas em tempo real por profissionais multidisciplinares envolvidos na prestação da assistência dos pacientes, melhorando a comunicação e qualidade durante o atendimento ao paciente. Apesar das vantagens proporcionadas pelo PEP, existem ainda muitos desafios a serem enfrentados, tais como o alto custo para a informatização adequada às Unidades Hospitalares e a resistência de parte dos profissionais da saúde em aderirem ao sistema. A pesquisa constitui um estudo de caso, cuja abordagem de pesquisa adotada foi á qualitativa e quantitativa, de natureza exploratória e descritiva. Foram analisadas 134 prescrições médicas manuscritas e 268 prescrições médicas eletrônicas, ambas analisadas em 30 dias consecutivos, considerando o período de análise determinado para cada fase do estudo. Das prescrições manuscritas 35% apresentavam rasuras e 89,1% apresentavam ilegibilidade em pelo menos um dos itens constantes da prescrição.

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.

Wenn ein Chirurg heutzutage während der Operation Informationen aus der Patientenakte benötigt, ist er gezwungen, sich entweder unsteril zu machen oder Personal anzuweisen, ihm die entspre-chenden Informationen zugänglich zu machen. Aus technischer Sicht ist ein System zur intraoperati-ven Bedienung und Darstellung sehr einfach zu realisieren. Grundlage dafür ist eine elektronische Patientenakte (EPA), welche beispielsweise softwaregenerierten oder eingescannten Dokumenten verwaltet. Die vorliegende Arbeit widmet sich den folgenden Fragen: Wird ein solches System im Operationssaal sinnvoll genutzt? Welche Methoden zur sterilen Bedienung kommen infrage? Wie muss die grafische Darstellung auf den Operationssaal abgestimmt werden? Kann durch das Imple-mentieren aktueller Kommunikationsstandards auf alle verfügbaren Patientendaten zugegriffen werden? Dazu wurden in einer ambulanten HNO-Klinik zwei Pilotstudien durchgeführt. In der ersten Studie wurde das erste auf dem Markt befindliche kommerzielle Produkt „MI-Report“ der Firma Karl Storz evaluiert, welches per Gestenerkennung bedient wird. Für die zweite Studie wurde ein EPA-System entwickelt (Doc-O-R), welches eine Vorauswahl der angezeigten Dokumente in Abhängigkeit des Eingriffs traf und mit einem Fußschalter bedient werden konnte. Pro System wurden ca. 50 Eingriffe dokumentiert. Dabei wurde jedes angesehene Dokument und der Nutzungsgrund protokolliert. Die Systeme wurden durchschnittlich mehr als einmal pro Eingriff genutzt. Die automatische Vorauswahl der Dokumente zur Reduzierung der Interaktionen zeigte sehr gute Ergebnisse. Da das behandelte Thema noch in den Anfängen steckt, wird in der Arbeit am Ende auf die Vielzahl von Möglichkeiten eingegangen, welche bezüglich neuartiger Darstellungsmethoden, Bedienvorrich-tungen und aktueller Standardisierungsaktivitäten noch realisiert werden können. Dadurch werden zukünftig auch die Abläufe in der Chirurgie beeinflusst werden.:1 Einführung 13 1.1 Problemstellung 14 1.2 Stand der Wissenschaft und Technik 14 1.2.1 Überblick 15 1.2.2 Digitalisierung des Operationssaals 16 1.2.3 Verbreitung Elektronischer Datenverarbeitungssysteme im Krankenhaus 16 1.2.4 Definitionen zum Begriff der elektronischen Patientenakte 17 1.2.5 Aufbau eines EPA-Systems 20 1.2.6 Sterile Bedienkonzepte 20 1.2.7 Darstellung 27 1.2.8 Standardisierung 33 2 Aufgabenstellung 39 3 Materialien und Methoden 41 3.1 Klinik 41 3.1.1 Technischer Stand 41 3.1.2 Abläufe im IRDC 41 3.2 Protokollierung 43 3.3 Verwendete Dokumente 44 3.3.1 KIS-Übersicht 44 3.3.2 Audiogramm 45 3.3.3 Tympanogramm 46 3.3.4 Blutwerte 47 3.3.5 OP-Bericht 48 3.3.6 Rhinomanometrie 50 3.3.7 Computertomographie 50 3.3.8 Bilder vorangegangener Untersuchungen und Operationen 51 3.3.9 Radiologische Gutachten 52 3.3.10 Anamnese 53 3.3.11 Überweisung 54 3.3.12 Stimmbefund 55 3.4 Statistische Auswertung 55 3.4.1 Abhängigkeit des betrachteten Dokuments von der Art des Eingriffs 55 3.4.2 Bewertung des Algorithmus zur automatischen Vorauswahl der Dokumente 56 3.5 Vorbereitung 57 3.6 Studie „MI-Report“ 57 3.6.1 Anzeige 58 3.6.2 Sensor und Bedienung 59 3.6.3 Personen 59 3.6.4 Vorbereitung 60 3.6.5 Protokollierung 60 3.7 Studie „Doc-O-R“ 62 3.7.1 Klinik 63 3.7.2 Vorbereitung 64 3.7.3 Protokollierung 64 3.7.4 Metadaten 65 3.7.5 Softwareentwicklung 65 4 Ergebnisse 69 4.1.1 Statistische Auswertung 71 4.2 Studie „MI-Report“ 71 4.2.1 Aktivierung 72 4.2.2 Nutzung 72 4.3 Studie „Doc-O-R“ 75 4.3.1 Datenlage 75 4.3.2 Algorithmus 75 4.3.3 Nutzung 77 4.3.4 Phasen 78 4.3.5 Operateure 79 4.3.6 Revisionen 79 5 Diskussion 81 5.1 Nutzung 81 5.2 Schwächen des Studienaufbaus 82 5.3 Statistische Auswertung 83 5.4 Darstellung 83 5.5 Standards 83 5.5.1 Technische Faktoren 84 5.5.2 Emotionale Faktoren 84 5.5.3 Strategische Faktoren 84 5.5.4 Ökonomische Faktoren 85 5.5.5 Rechtliche Faktoren 85 5.5.6 Machtpolitische Faktoren 85 5.6 Studie „MI-Report“ 85 5.6.1 Grafische Oberfläche 85 5.6.2 Aktivierung 86 5.6.3 Nutzung 86 5.6.4 Schwächen des Studienaufbaus 87 5.7 Studie „Doc-O-R“ 88 5.7.1 Schwächen der Studie 88 5.7.2 Algorithmus 88 5.7.3 Darstellung 88 5.7.4 Bedienung 89 5.7.5 Phasen 89 5.7.6 Nutzung 89 5.7.7 Revisionen 90 6 Schlussfolgerung 91 6.1 Bedienung 91 6.2 Standardisierung 92 6.3 Darstellung 93 6.4 Nutzungsverhalten 94 7 Ausblick 97 7.1 Bedienung 98 7.2 Standardisierung 100 7.3 Darstellung 102 7.4 Nutzungsverhalten 104 8 Zusammenfassung der Arbeit 105 9 Abbildungsverzeichnis 109 10 Quellenangaben 112 Anhang A Anatomische und physiologische Grundlagen 119 Anhang B Ambulante Eingriffe in der HNO-Chirurgie 121 Anhang C Schematischer Aufbau des Operationstraktes 123

Der Nutzen von Telemedizin und Telecare/Homecare ist heute nicht mehr umstritten. Es existiert eine große Anzahl von Lösungen und Konzepten. Zum Teil werden sie bereits in der Routine eingesetzt. Die Systeme sind in der Regel vom Typ "stand-alone" bzw. "Insellösung". Ansätze einer Plattformtechnologie sind bei einigen Systemen erkennbar. Gemeinsame Probleme der vorhandenen Lösungen liegen im Bereich fehlender Standardisierung von Dateninhalten und Verfahren sowie einer soliden gesetzlichen und abrechnungstechnischen Grundlage. Von diesem Zustand bis zum flächendeckenden Einsatz von Telemedizin/Telecare ist noch ein weiter Weg. Die vorliegende Arbeit beschäftigt sich vorwiegend mit einem Teilaspekt dieses breiten Themas. Es ist die Frage, wie Telemedizin und Telecare sich optimal in den Arbeitsablauf eines Allgemeinmediziners integrieren lassen. Die Analyse zeigte, dass die Probleme in folgenden Bereichen zu finden sind: * Fehlende allgemeine und internationale Telemedizin-Plattform * Fehlende zentrale elektronische Patientenakte * Unzureichende Offenheit der Praxissoftware * Unzureichende Ko-Existenz von herkömmlichen und telemedizinischen Lösungen * Unzureichende gesetzliche und abrechnungstechnische Grundlage Folgerichtig muss ein Anforderungskatalog aufgestellt werden, der hilft, diese Mängel zu beseitigen. Auf der Basis dieses Anforderungskatalogs wurde ein Konzept entwickelt, in dessen Zentrum die allgemein-medizinische Praxis steht. Im Hintergrund der Praxis ist eine auf vorhandenen Standards fußenden Plattform, die eine flächendeckende Kommunikation aller Teilnehmer ermöglicht, vom Patienten über den Arzt bis zur Fachklinik, Apotheke und Kassenärztlichen Vereinigung sowie Versicherungen. Der Anschluss der Praxissoftware an diese Plattform ist eine wesentliche Voraussetzung zur Implementierung. Ein wichtiger Bestandteil des Konzeptes ist der Vorschlag einer international anerkannten Ontologie (UMLS), die neben der Vereinheitlichung der Dateninhalte auch bei der Internationalisierung helfen wird. Hier werden die gesetzlichen Aspekte nur soweit behandelt, als sie der klaren Vorgabe der Konzeption dienen. Die Implementierung ist nicht in einem Schnellgang möglich. Der Grund liegt darin, dass hier neben den in der Regel langwierigen Gesetzgebungsprozessen eine große Anzahl von Verbänden Mitbestimmung geltend macht, deren Interessen oft in entgegengesetzte Richtungen wirken. Es wird daher notwendig sein, die Einführung erstens schrittweise und zweitens immer im Gleichschritt mit diesen Organen zu gestalten. Ist dies jedoch gelungen, eine solche Plattform zu etablieren, so ergibt sich hieraus ein breites Spektrum von Anwendungsgebieten, wie ein weltweites Gesundheitssystem, bei dem der Patient überall auf der Welt die gleiche medizinische Behandlung wie in seinem Heimatland erfährt. / Today there is no question that telemedicine and telecare/homecare can provide benefit to their users. A large number of such systems are available. Partially they are used for daily works. Normally they are stand-alone, without an underlying platform. In the last few years one can recognize the beginning of a platform technology. The most common problems of existing solutions are caused by the lack of standardisation of data items and procedures, the lack of a reliable legal basis and billing possibilities. It is a long way to go to get the telemedicine/telecare running. This document describes a sub-aspect of the large topic telemedicine/telecare. It includes the question how one can integrate telemedicine/telecare into the daily workflow of a private doctor office. The system analysis shows that problems occurring during the integration can be subdivided into following topics: * Lack of a general and international telemedicine platform * Lack of a generally accepted electronic patient record * Lack of a interoperability of the medical information systems * Lack of a harmonized co-existence of telemedicine and medical works * Lack of a legal basis and billing possibilities As a consequence of the analysis` results a catalogue of requirements must be established which provides the basis for a system concept. The central point of the concept must be the doctor office. Its background should be a set of standards which establishes the platform for the communication between every participant to the telemedicine: patients, doctors, clinics, pharmacy, medical invoice organisations and insurance companies. The most essential requirement to implement this platform is the connection of the IT equipment in private doctor offices to the applications and databases of the platform. The key feature of the proposed concept is the integration of a international accepted ontology. We recommend the UMLS concept of the NIH. UMLS provide a set of standardized terms, the so called "concepts", and the possibilities to implement multilingual applications. In this document legal aspects are discussed only if they can contribute to the construction of the platform. Due to the never ending legislative process and the opposite interest of the participants to the platform a high-speed implementation of the platform can not be expected. A stepwise implementation which continuously accompanies the legislative processes is therefore required. However based on a successful implementation of the platform the gate is open to a large range of applications in a widely used healthcare system which can provide medical care to every patient at any time and at any location - worldwide - on the same quality level like in his home country.

Os recentes avanços nas tecnologias de comunicação e computação viabilizaram o pronto acesso às informações do prontuário eletrônico do paciente (PEP). O potencial de difusão de informações clínicas resultante suscita preocupações acerca da priva-cidade do paciente e da confidencialidade de seus dados. As normas presentes na legislação dispõem que o conteúdo do prontuário deve ser sigiloso, não cabendo o acesso a ele sem a prévia autorização do paciente, salvo quando necessário para be-neficiá-lo. Este trabalho propõe o MACA, um modelo de autorização contextual para o controle de acesso baseado em papéis (CABP) que contempla requisitos de limita-ção de acesso ao PEP em ambientes abertos e distribuídos. O CABP regula o acesso dos usuários ao PEP com base nas funções (papéis) que eles exercem numa organi-zação. Uma autorização contextual usa informações ambientais disponíveis durante o acesso para decidir se um usuário tem o direito e a necessidade de acessar um re-curso do PEP. Isso confere ao MACA flexibilidade e poder expressivo para estabele-cer políticas de acesso ao PEP e políticas administrativas para o CABP que se adap-tam à diversidade ambiental e cultural das organizações de saúde. O MACA ainda permite que os componentes do PEP utilizem o CABP de forma transparente para o usuário final, tornando-o mais fácil de usar quando comparado a outros modelos de CABP. A arquitetura onde a implementação do MACA foi integrada adota o serviço de diretórios LDAP (Lightweight Directory Access Protocol), a linguagem de pro-gramação Java e os padrões CORBA Security Service e Resource Access Decision Fa-cility. Com esses padrões abertos e distribuídos, os componentes heterogêneos do PEP podem solicitar serviços de autenticação de usuário e de autorização de acesso de modo unificado e coerente a partir de múltiplas plataformas. A implementação do MACA ainda tem a vantagem de ser um software livre, de basear-se em componen-tes de software sem custos de licenciamento e de apresentar bom desempenho para as demandas de acesso estimadas. Por fim, a utilização rotineira do MACA no con-trole de acesso ao PEP do InCor-HC.FMUSP, por cerca de 2000 usuários, evidenciam a exeqüibilidade do modelo, da sua implementação e da sua aplicação prática em casos reais. / The recent advances in computing and communication technologies allowed ready access to the electronic patient record (EPR) information. High availability of clinical information raises concerns about patients privacy and data confidentiality of their data. The legal regulation mandates the confidentiality of EPR contents. Everyone has to be authorized by the patients to access their EPR, except when this access is necessary to provide care on their behalf. This work proposes MACA, a contextual authorization model for the role-based access control (RBAC) that considers the ac-cess restrictions requirements for the EPR in open and distributed environments. RBAC regulates user’s access to EPR based on organizational functions (roles). Con-textual authorizations use environmental information available at access time, like user/patient relationship, in order to decide whether a user is allowed to access an EPR resource. This gives flexibility and expressive power to MACA, allowing one to establish access policies for the EPR and administrative policies for the RBAC that considers the environmental and cultural diversity of healthcare organizations. MACA also allows EPR components to use RBAC transparently, making it more user friendly when compared with other RBAC models. The implementation of MACA architecture uses the LDAP (Lightweight Directory Access Protocol) directory server, the Java programming language and the standards CORBA Security Service and Re-source Access Decision Facility. Thus, heterogeneous EPR components can request user authentication and access authorization services in a unified and coherent way across multiple platforms. MACA implementation complies with free software pol-icy. It is based on software components without licensing costs and it offers good performance for the estimated access demand. Finally, the daily use of MACA to control the access of about 2000 users to the EPR at InCor-HC.FMUSP shows the feasibility of the model, of its implementation and the effectiveness of its practical application on real cases.

Os recentes avanços nas tecnologias de comunicação e computação viabilizaram o pronto acesso às informações do prontuário eletrônico do paciente (PEP). O potencial de difusão de informações clínicas resultante suscita preocupações acerca da priva-cidade do paciente e da confidencialidade de seus dados. As normas presentes na legislação dispõem que o conteúdo do prontuário deve ser sigiloso, não cabendo o acesso a ele sem a prévia autorização do paciente, salvo quando necessário para be-neficiá-lo. Este trabalho propõe o MACA, um modelo de autorização contextual para o controle de acesso baseado em papéis (CABP) que contempla requisitos de limita-ção de acesso ao PEP em ambientes abertos e distribuídos. O CABP regula o acesso dos usuários ao PEP com base nas funções (papéis) que eles exercem numa organi-zação. Uma autorização contextual usa informações ambientais disponíveis durante o acesso para decidir se um usuário tem o direito e a necessidade de acessar um re-curso do PEP. Isso confere ao MACA flexibilidade e poder expressivo para estabele-cer políticas de acesso ao PEP e políticas administrativas para o CABP que se adap-tam à diversidade ambiental e cultural das organizações de saúde. O MACA ainda permite que os componentes do PEP utilizem o CABP de forma transparente para o usuário final, tornando-o mais fácil de usar quando comparado a outros modelos de CABP. A arquitetura onde a implementação do MACA foi integrada adota o serviço de diretórios LDAP (Lightweight Directory Access Protocol), a linguagem de pro-gramação Java e os padrões CORBA Security Service e Resource Access Decision Fa-cility. Com esses padrões abertos e distribuídos, os componentes heterogêneos do PEP podem solicitar serviços de autenticação de usuário e de autorização de acesso de modo unificado e coerente a partir de múltiplas plataformas. A implementação do MACA ainda tem a vantagem de ser um software livre, de basear-se em componen-tes de software sem custos de licenciamento e de apresentar bom desempenho para as demandas de acesso estimadas. Por fim, a utilização rotineira do MACA no con-trole de acesso ao PEP do InCor-HC.FMUSP, por cerca de 2000 usuários, evidenciam a exeqüibilidade do modelo, da sua implementação e da sua aplicação prática em casos reais. / The recent advances in computing and communication technologies allowed ready access to the electronic patient record (EPR) information. High availability of clinical information raises concerns about patients privacy and data confidentiality of their data. The legal regulation mandates the confidentiality of EPR contents. Everyone has to be authorized by the patients to access their EPR, except when this access is necessary to provide care on their behalf. This work proposes MACA, a contextual authorization model for the role-based access control (RBAC) that considers the ac-cess restrictions requirements for the EPR in open and distributed environments. RBAC regulates user’s access to EPR based on organizational functions (roles). Con-textual authorizations use environmental information available at access time, like user/patient relationship, in order to decide whether a user is allowed to access an EPR resource. This gives flexibility and expressive power to MACA, allowing one to establish access policies for the EPR and administrative policies for the RBAC that considers the environmental and cultural diversity of healthcare organizations. MACA also allows EPR components to use RBAC transparently, making it more user friendly when compared with other RBAC models. The implementation of MACA architecture uses the LDAP (Lightweight Directory Access Protocol) directory server, the Java programming language and the standards CORBA Security Service and Re-source Access Decision Facility. Thus, heterogeneous EPR components can request user authentication and access authorization services in a unified and coherent way across multiple platforms. MACA implementation complies with free software pol-icy. It is based on software components without licensing costs and it offers good performance for the estimated access demand. Finally, the daily use of MACA to control the access of about 2000 users to the EPR at InCor-HC.FMUSP shows the feasibility of the model, of its implementation and the effectiveness of its practical application on real cases.

Submitted by RICARDO CÉSAR DE CARVALHO (ricdon@gmail.com) on 2017-06-02T04:41:34Z No. of bitstreams: 1 Mestrado_Ricardo_Carvalho.pdf: 4464660 bytes, checksum: ba1819b77212278eb1a2808fd9658e4c (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-06-02T13:47:17Z (GMT) No. of bitstreams: 1 carvalho_rc_me_mar.pdf: 4464660 bytes, checksum: ba1819b77212278eb1a2808fd9658e4c (MD5) / Made available in DSpace on 2017-06-02T13:47:17Z (GMT). No. of bitstreams: 1 carvalho_rc_me_mar.pdf: 4464660 bytes, checksum: ba1819b77212278eb1a2808fd9658e4c (MD5) Previous issue date: 2017-05-08 / Na área da saúde, as tecnologias digitais fornecem recursos para a geração, controle, manutenção e arquivamento dos dados vitais dos pacientes, pesquisas biomédicas, captura e disponibilização de imagens diagnósticas. Ao criar grandes bancos de dados sobre a saúde das pessoas, o processamento das informações contidas no prontuário do paciente permitirá uma nova visão a respeito do conhecimento atual do processo de diagnóstico médico. Existem diversos problemas nessa área, porque o acesso ao prontuário analógico é complicado, e em formato eletrônico não está disponível para todos, apesar do conhecido potencial desses documentos como fonte informacional. Uma das formas para a organização desse conhecimento é por meio da mineração de textos, que possibilita o processamento dos dados descritos em linguagem natural. Entretanto, é preciso levar em consideração o fato da redação médica não poder ser padronizada, embora exista a normativa do Conselho Federal de Medicina que orienta nessa direção. É neste contexto, que esta pesquisa se norteia com o objetivo básico de investigar a aplicabilidade da metodologia de mineração de textos para a extração de informações provenientes da anamnese de prontuários eletrônicos do paciente divulgados no ciberespaço visando a qualidade na recuperação de informações. Trata-se de uma pesquisa de cunho exploratório, tendo-se realizado a mineração de textos sobre um conjunto de 46 anamneses divulgadas no ciberespaço visando a recuperação de informação. Em seguida, fez-se um cotejamento com os dados recuperados de forma manual, efetuando-se a interpretação da linguagem de comunicação médico-paciente. Esses dois resultados foram registrados em um protótipo construído e simulando o ambiente de um consultório médico. Os resultados evidenciam que a utilização da mineração de texto como ferramenta de extração na busca e recuperação de informações em saúde encontrou diversas dificuldades decorrentes das inúmeras formas de se redigir uma anamnese, além dos erros ortográficos, erros gramaticais, remoção de sufixos e prefixos, sinônimos, abreviações, siglas, símbolos, pontuações, termos e jargões médicos. Esse fato evidencia que ao se planejar um sistema computacional ele deve ser capaz de interpretar informações descritas de inúmeras formas, não excluindo palavras importantes ou ignorando aqueles relevantes que poderiam colocar em risco as ações de cuidados do paciente. Ao aplicar os processos de tokenization, remoção de stopwords, normalização morfológica, stemming e cálculo da relevância, conjuntamente contribuíram para que os termos resultantes fossem muito diferentes daqueles extraídos manualmente, ou seja, há ainda muitos desafios em cada uma dessas etapas na busca da qualidade na recuperação de informações concernente à anamnese. Conclui-se que embora a mineração seja uma ferramenta útil ao se tratar de textos estruturados e de outros domínios, quando aplicada a anamnese que é um texto mais livre tal ferramenta deixa a desejar, posto que ao se tratar da área da saúde, a redução de termos compostos, bem como a utilização de siglas, símbolos, abreviaturas ou outra forma de redução linguística trará interferências danosas para a recuperação de informação. A construção do protótipo ilustra a criação de uma ferramenta leve e intuitiva aplicando os conceitos discutidos nessa dissertação, além de se tornar o pontapé inicial de trabalhos futuros. / In the health area, digital technologies provide resources for the generation, control, maintenance and vital patient data archiving biomedical research, diagnostic images capture and availability. By creating large databases on people´s health records, processing the information contained in the patient's medical record, will provide a new insight into current knowledge of the medical diagnostic process. There are several problems in this area, because the access to analogical records is very complex and electronic format is not available for all of them, despite the known potential of these documents as informational source. One of the ways to arrange this knowledge is by the text mining which enables the data processing in natural language. However, it is necessary to consider the fact that medical writing cannot be standardized, although there is a Federal Council of Medicine policy that directs to that path. This is the context which this research is guided by the basic goal of investigating the methodology applicability of text mining for extracting information from the anamnesis of patients' electronic medical records divulged in cyberspace and aiming at the quality of information retrieval. This is an exploratory research, with texts mining on a set of 46 anamnesis published in cyberspace aimed at information retrieval. Then, a comparison was made with the data retrieved manually, to the interpretation of the medical-patient communication language. Those two results were recorded in a prototype built and simulating the environment of a doctor's office. The results show that the use of text mining as an extraction tool in the search and retrieval of health information has found several difficulties due to the numerous ways of writing an anamnesis, besides spelling errors, grammatical errors, deletion of suffixes and prefixes, synonyms, abbreviations, acronyms, symbols, punctuations, medical terms and jargon. It shows that when planning a computer system, it should be able to interpret information described in different ways, not excluding important words or ignoring relevant ones that could jeopardize patient care actions. By applying the processes of tokenization, stopwords, morphological normalization, stemming and calculus of relevance, altogether contributed to showing that the resulting terms were very different from those extracted manually. There are still many challenges in each of those steps concerning quality in the anamnesis information retrieval. Concluding that although mining is a useful tool when dealing with structured texts and other domains, when applied to anamnesis, which is a freer text, such tool lacks efficiency, since in health area the compound terms reduction, as well as the use of acronyms, symbols, abbreviations or other forms of linguistic reduction will bring harmful interference to the retrieval of information. The prototype is a light and intuitive tool applied to the concepts discussed on this dissertation, which way become the kickoff of a future project.

À l’instar de plusieurs systèmes de santé, les centres hospitaliers québécois ont amorcé l’informatisation du dossier patient sous forme papier pour la transition vers un dossier clinique informatisé (DCI). Ce changement complexe s’est parfois traduit par des répercussions sur les pratiques de soins, la sécurité et la qualité des soins offerts. L’adoption de la part des utilisateurs de technologies de l’information (TI) est considérée comme un facteur critique de succès pour la réalisation de bénéfices suite au passage à un DCI. Cette étude transversale multicentrique avait pour objectifs d’examiner des facteurs explicatifs de l’adoption, de l’utilisation réelle d’un DCI, de la satisfaction des infirmières et de comparer les résultats au regard du sexe, de l’âge, de l’expérience des infirmières et des stades de déploiement du DCI. Un modèle théorique s’appuyant sur la Théorie unifiée de l’adoption et de l’utilisation de la technologie a été développé et testé auprès d’un échantillon comptant 616 infirmières utilisant un DCI hospitalier dans quatre milieux de soins différents. Plus particulièrement, l’étude a testé 20 hypothèses de recherche s’intéressant aux relations entre huit construits tels la compatibilité du DCI, le sentiment d’auto-efficacité des infirmières, les attentes liées à la performance, celles qui sont liées aux efforts à déployer pour adopter le DCI, l'influence sociale dans l’environnement de travail, les conditions facilitatrices mises de l’avant pour soutenir le changement et ce, relativement à l’utilisation réelle du DCI et la satisfaction des infirmières. Au terme des analyses de modélisation par équations structurelles, 13 hypothèses de recherche ont été confirmées. Les résultats tendent à démontrer qu’un DCI répondant aux attentes des infirmières quant à l’amélioration de leur performance et des efforts à déployer, la présence de conditions facilitatrices dans l’environnement de travail et un DCI compatible avec leur style de travail, leurs pratiques courantes et leurs valeurs sont les facteurs les plus déterminants pour influencer positivement l’utilisation du DCI et leur satisfaction. Les facteurs modélisés ont permis d’expliquer 50,2 % de la variance des attentes liées à la performance, 52,9 % des attentes liées aux efforts, 33,6 % de l’utilisation réelle du DCI et 54,9 % de la satisfaction des infirmières. La forte concordance du modèle testé avec les données de l’échantillon a notamment mis en lumière l’influence des attentes liées à la performance sur l’utilisation réelle du DCI (r = 0,55 p = 0,006) et sur la satisfaction des infirmières (r = 0,27 p = 0,010), des conditions facilitatrices sur les attentes liées aux efforts (r = 0,45 p = 0,009), de la compatibilité du DCI sur les attentes liées à la performance (r = 0,39 p = 0,002) et sur celles qui sont liées aux efforts (r = 0,28 p = 0,009). Les nombreuses hypothèses retenues ont permis de dégager l’importance des effets de médiation captés par le construit des attentes liées à la performance et celui des attentes liées aux efforts requis pour utiliser le DCI. Les comparaisons fondées sur l’âge, l’expérience et le sexe des répondants n’ont décelé aucune différence statistiquement significative quant à l’adoption, l’utilisation réelle du DCI et la satisfaction des infirmières. Par contre, celles qui sont fondées sur les quatre stades de déploiement du DCI ont révélé des différences significatives quant aux relations modélisées. Les résultats indiquent que plus le stade de déploiement du DCI progresse, plus on observe une intensification de certaines relations clés du modèle et une plus forte explication de la variance de la satisfaction des infirmières qui utilisent le DCI. De plus, certains résultats de l’étude divergent des données empiriques produites dans une perspective prédictive de l’adoption des TI. La présente étude tend à démontrer l’applicabilité des modèles et des théories de l’adoption des TI auprès d’infirmières œuvrant en centre hospitalier. Les résultats indiquent qu’un DCI répondant aux attentes liées à la performance des infirmières est le facteur le plus déterminant pour influencer positivement l’utilisation réelle du DCI et leur satisfaction. Pour la gestion du changement, l’étude a relevé des facteurs explicatifs de l’adoption et de l’utilisation d’un DCI. La modélisation a aussi mis en lumière les interrelations qui évoluent en fonction de stades de déploiement différents d’un DCI. Ces résultats pourront orienter les décideurs et les agents de changement quant aux mesures à déployer pour optimiser les bénéfices d’une infostructure entièrement électronique dans les systèmes de santé. / Like many other healthcare systems, healthcare institutions in Quebec are in the process of transitioning from paper-based patient records to Electronic Patient Records (EPRs). For some time now, this considerable and complex transition has had a high failure rate and unexpected consequences on care practices and the quality and safety of the care provided to patients. The acceptance of information technology by users is considered to be a critical success factor in realizing the benefits of EPR implementation. The goal of this multicenter cross-sectional study was to examine the explanatory factors of the adoption and actual use of an EPR by nurses and their satisfaction. It also aimed at comparing the outcomes by gender, age and experience and by EPR adoption stage. To do so, a theoretical model based on the unified theory of acceptance and use of technology (UTAUT) was developed and tested on a sample of 616 nurses who use an EPR in four different acute care facilities. Specifically, the study tested 20 research hypotheses on the relationships among eight different constructs, namely EPR compatibility, self-efficacy, performance expectancy, effort expectancy, social influence, facilitating conditions explaining the actual use of an EPR by nurses and their satisfaction. Fifteen research hypotheses were supported following structural equation modeling analysis. The results revealed that performance expectancy, effort expectancy, facilitating conditions and compatibility of the EPR (with preferred work style, existing work practices and values of nurses) were strong determinants of the actual use of an EPR by nurses and their satisfaction. The variables explained 50.2% of the variance of performance expectancy, 52.9% of effort expectancy, 33.6% of actual use of an EPR by nurses and 54.9% of their satisfaction. The strong fit of the model tested with the sample data showed the influence of performance expectancy on the actual use of the EPR by nurses (r = .55 p = .006) and on their satisfaction (r = .27 p = .010), the influence of the facilitating conditions on effort expectancy (r = .45 p = .009), EPR compatibility on performance expectancy (r = .39 p = .002) and on effort expectancy (r = .28 p = .009). The numerous hypotheses supported highlight the importance of the mediation effects captured by the performance expectancy and effort expectancy constructs. Comparisons based on age, experience and gender of the respondents did not reveal any statistically significant differences in terms of the acceptance and actual use of an EPR by nurses and their satisfaction. However, those based on the four EPR adoption stages revealed significant differences in terms of the relationships modelled. The results suggest that certain key relationships become more intense as the EPR adoption stages progress, thereby providing a better explanation of the variance in the satisfaction of nurses. Some results of the study also differ from the empirical data produced in a predictive perspective of information technology adoption. The study shows the applicability of the technology acceptance models and theories for nurses working in hospital centres. The results suggest that an EPR that meets performance expectancies is the most determining factor in positively influencing the actual use of the EPR and the satisfaction of nurses. To manage change, the study identified some explanatory factors of the acceptance and use of an EPR, and the model testing revealed how the relationships evolve based on the various EPR adoption stages. The results could help guide decision makers and change agents in determining the measures to implement in order to maximize the benefits of a fully electronic infostructure in healthcare systems.