Implementation of electronic health records (EHRs) is a driver for the improvement of health care and the reduction of health care costs. Developing countries face substantial challenges in adopting EHRs. The complex adaptive system conceptual framework was used to guide this single case study to explore strategies that health care leaders used to successfully implement the EHR system. Data were collected from 6 health care leaders from an island in the Caribbean using a semistructured interview technique. Data were analyzed using the Bengtsson's 4-stage data analysis process, which includes decontextualization, recontextualization, categorization, and compilation. The results of the study yielded 5 main themes: training, increased staffing, monitoring, identifying organizational gaps, and time. The implications of the study for positive social change include the potential to improve the standards of care provided to promote improved patient outcomes by using the strategies identified in this study to successfully implement the EHR system.

The population of older adults is growing worldwide, particularly in North America. Health information technology (HIT) is a group of technologies and systems that enhance care by electronically storing, managing, and exchanging data. HIT presents opportunities to support older adults' healthcare needs in communities and long-term care (LTC) environments. Despite their potential benefits, these technologies remain limited in LTC and older adults' healthcare contexts. Evidence is scattered on the factors that affect older adults' adoption of HIT. Little research has investigated the adoption of these technologies by formal healthcare providers and the technologies' impacts on LTC. A multi-method approach was employed in this thesis research, using a combination of a systematic qualitative review, an inductive semi-qualitative Delphi survey, and a quantitative deductive study to manage each research question in order to address these gaps. The systematic literature review used the PRISMA guidelines to identify and critically appraise studies that examined the effect of various HIT adoption factors among older adults in the community. The search involved five databases and a combination of keywords, resulting in the selection of critically appraised articles based on their evidence level and research rigor. A coding scheme was developed to extract information from the selected articles. The results showed that the main factors affecting HIT adoption by older adults relate to performance expectancy, effort expectancy, and high price/cost value. It also highlighted the importance of considering privacy/security and product design when evaluating HIT adoption by older adults. In light of the limited available studies on HIT adoption and impacts in the context of LTC, a Delphi study was developed to collect data from key formal healthcare providers (i.e., nurses) working in LTC at one of the largest and most progressive older adult healthcare facilities in Ontario, Canada. The Delphi study aimed to identify and prioritize the key factors that affect nurses' adoption of new technologies in support of older adults' care. A panel of nurses was solicited to participate in the Delphi study, which involved three rounds of data collection: brainstorming, narrowing down, and ranking. A total of 20 nurses completed the Delphi study, and the top factors that the LTC nurses identified were mainly related to the organizational and technological dimensions, including the complexity of HIT, the training and support provided, the interoperability of HIT systems, the cost of implementation, and the availability of HIT infrastructure. For the last part of this research, quantitative secondary data analysis was conducted on a Canadian national survey of nurses to examine their perceived impacts of HIT adoption by nurses in LTC. The survey included questions related to the current state of electronic medical records (EMR) and EMR adoption, the state of virtual care technologies, attitudes and perceptions related to access and the impact of the adoption of digital health technologies in practice, benefits and effects of EMR adoption, and barriers preventing nurses from getting total value from electronic health. A subset of 166 nursing homes/long-term care facilities/older adult residences and homecare nurses were selected for this analysis. Data management and analysis were conducted using IBM SPSS v28. The results showed that HIT adoption by nurses in LTC was positively associated with perceived benefits and organizational support. However, HIT adoption was negatively associated with perceived complexity and privacy/security concerns. This thesis research suggests that HIT adoption by older adults and nurses in LTC is complex and multifaceted, requiring attention to individual, organizational, and technological factors. There is a need for improved communication and collaboration among LTC team members and better working conditions to improve staff well-being and reduce turnover. The findings from the systematic review and Delphi study contribute to the theoretical understanding of the factors influencing the adoption of HIT in LTC facilities. The survey results provide valuable insights into the current state of HIT use in LTC facilities and can be used to inform the development of targeted interventions to improve HIT adoption and use. Overall, this study contributes to the growing body of knowledge on HIT adoption in LTC facilities and provides important recommendations for policymakers, administrators, and LTC staff to improve the use of HIT and ultimately enhance the quality of the care supplied to LTC residents.

Information technology is ubiquitous in society and industry; however, healthcare is just beginning to explore how health information technology (HIT) can be optimized to support quality care. HIT can assist with standardizing care delivery, increasing access to evidence-based medicine, improving accuracy and ease of documentation, and assisting with patient education. Advanced Practice Registered Nurses (APRNs), specifically nurse practitioners (NPs) and certified nurse midwives (CNMs), play a pivotal role in the healthcare delivery system. To be effective practitioners, providers must manage, integrate, and assimilate a multitude of knowledge with each patient encounter. HIT can serve as the channel through which the NP and CNM provides cost-effective, efficient, and quality care. However, healthcare providers have been slow to adopt and implement HIT resources. We know that adoption of HIT by healthcare providers is varied among provider and practice settings. However, few studies have examined the impact on and utilization of information technology by APRNs, specifically nurse practitioners and certified nurse midwives.The purpose of this research was to investigate the utilization and influence of HIT on the clinical decision making of Kentucky nurse practitioners and nurse midwives (Kentucky APRNs). A descriptive cross-sectional design using survey methodology and convenience sampling was employed. Participants were asked to complete an author-modified, web-based survey tool that was based on current research. The 40-question tool was designed to explore providers' attitudes and perceptions of technology, determine their knowledge and utilization of various electronic and traditional print medical resources, and assess the penetration of and daily usage of HIT in practice.This study revealed information related to Kentucky APRN's utilization and influence of HIT on clinical decision making. Establishing exploratory Kentucky APRN findings will assist in evaluating further HIT utilization in Kentucky. Findings suggested that APRNs in Kentucky are beginning to explore the benefits of HIT; however, additional research will be required to identify the true penetration and utilization of technology in Kentucky. Although additional research is needed, HIT appears to be having an overall impact on the clinical practice of Kentucky APRNs.

Background: Health information exchange technologies are currently being implemented in many practice settings with the promise to improve quality, efficiency, and costs of care. The benefits are likely highest in settings where entry into the healthcare system is gained; however, in no setting is the need for timely, accurate, and pertinent information more critical than in the emergency department (ED). This study evaluated the use of a payer-based electronic health record (EHR) in an ED on quality, efficiency, and costs of care among a commercially insured population.Methods: Data came from a large health plan and the ED of a large urban ED. Visits with the use of a payer-based EHR were identified from claims between 9/1/05 and 2/17/06. A historical comparison sample of visits was identified from 11/1/04 to 3/31/05. Outcomes included return visits, ED duration, use of laboratory and diagnostic imaging, total costs during and in the four weeks after, and prescription drug utilization.Results: A total of 2,288 ED visits were analyzed (779 EHR visits and 1,509 comparison visits). Discharged visits were associated with an 18 minute shorter duration (95% CI: 5-33); whereas, the EHR among admitted visits was associated with a 77 minute reduction (95% CI: 28-126). The EHR was also associated with $1,560 (95% CI: $43-$2,910) savings in total plan paid for the visit among admitted visits. No significant differences were observed on return visits, laboratory or diagnostic imaging services and total costs over the four week follow-up. Exploratory analyses suggested that the EHR may be associated with a reduction in the number of prescription drugs used among chronic medication users.Conclusion: The EHR studied was associated with a significant reduction in ED duration. Technologies that can reduce ED lengths of stay can have a substantial impact on the care provided to patients and their satisfaction. The data suggests that the EHR may be associated with lower health plan paid amounts among admitted visits and a reduction in the number of pharmacy claims after the visit among chronic users of prescription drugs. Additional research should be conducted to confirm these findings.

Abstract PATTERNS IN CHAPLAIN DOCUMENTATION OF ASSESSMENTS AND INTERVENTIONS, A DESCRIPTIVE STUDY by Kevin Eugene Adams, MDiv A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University, 2015 Diane Dodd-McCue, D.B.A, Department of Patient Counseling There is increasing emphasis on the importance of evidence-based care provided by all disciplines in healthcare. The Electronic Health Record (EHR) is becoming the standard for communicating assessments, plans of care, interventions, and outcomes of patient care. The spiritual care literature demonstrates the importance of assessing religious/spiritual needs and resources and developing plans of care to address the results of such assessment (Anandarajah & Hight, 2001; Borneman, Ferrell, & Puchalski, 2010; Fitchett, 1999; Fitchett & Risk, 2009; H. G. Koenig, 2007). This literature also suggests that addressing religious/spiritual needs of patients and families in the healthcare context can affect healthcare and adherence outcomes. The purpose of this study was to identify patterns of chaplain assessment and patterns of chaplain provision of services. This descriptive study was an exploratory retrospective analysis of categorical data recorded by clinical staff chaplains in the EHR at a single all pediatric healthcare institution, using contingency tables and frequency tables. The study examined chaplain use of assessment and service descriptors and the patterns of these descriptors when documenting chaplain visits. The results indicate chaplain preference for communicating in the EHR using general themes and concepts. This reveals an opportunity for chaplains to develop and implement a model of professional identity and articulation of care that is broad enough to accommodate the diversity of religion/spirituality chaplains encounter, yet able to articulate the specifics of patient and family religion/spirituality. The results found no consistent patterns among assessments or services provided. Further, the results found no indication of patterns between assessments made and the services provided. This presents an opportunity for chaplains to develop and implement a theory-driven, construct-based model of care that will connect the different facets of spiritual care. The assessments made will lead to plans of care that involve specific interventions resulting in appropriate outcomes related to overall patient and family care.

The purpose of this study was to identify the effects of the prospective payment system on coding practices, resource allocations, quantitative and quantitative standards and organizational structure in medical record departments of 108 acute care, general medical and surgical hospitals in Kentucky. The study results revealed changes in coding practices consistent with the demand under the prospective payment system for more timely, complete and accurate information for billing purposes. Additionally, accurate data were needed to establish a reliable case-mix data base upon which future reimbursement formulas would be based. Increases in human and capital resources, especially in the area of software purchases to enhance the coding function were documented. Standards to measure coding quality and quantity had not been consistently developed in Kentucky hospitals. Use of developed coding standards for performance evaluation of coders was not widespread. Activities to optimize reimbursement 'ere employed by hospitals mostly on a concurrent basis. An organizational shift of the medical record department responsibilities to the finance area was not documented. However, a greater interdependence and cooperative relationship occurred between medical records, finance, administration and the medical staff.

Presently, self-tracking applications are used to help patients with chronic illness management. For example, applications ask users to track mood through online diaries or snap photos of their food content in order to analyze patterns correlated to their chronic disease. Although these health care applications are on the market today, there still exists a fundamental challenge in motivating participants to consistently update and enter information. Therefore, the focus of this thesis is on reducing the fatigue from using these applications. Pulling from user social media data will almost completely eliminate the capture burden placed on participants, since users will only have to continue to use social media as they regularly do. Instead of analyzing manually inputted data, patterns can be found between social media data and chronic diseases. A Microsoft Research team found indicators in public user Twitter data associated with the onset of a depressive episode. They were able to create a predictor tool, predicting the onset of a depressive episode, with 70 percent accuracy. Using this research alongside expert feedback, our aim is to design an interface used by both clinician and patient that will provide them with a timeline marking spikes in Twitter indicators correlated to a patient’s depressive episode.

Acute kidney injury (AKI) is a significant adverse effect of many medications that leads to increased morbidity, cost, and mortality among hospitalized patients. Recent literature supports a strong link between empiric combination antimicrobial therapy and increased AKI risk. As briefly summarized below, the following chapters describe my research conducted in this area. Chapter 1 presents and summarizes the published literature connecting combination antimicrobial therapy with increased AKI incidence. This chapter sets the specific aims I aim to achieve during my dissertation project. Chapter 2 describes a study in which patients receiving vancomycin (VAN) in combination with piperacillin-tazobactam (TZP) or cefepime (CFP). I matched over 1,600 patients receiving both combinations and found a significantly lower incidence of AKI among patient receiving the CFP+VAN combination when controlling for confounders. The conclusion of this study is that VAN+TZP has significantly increased risk of AKI compared to CFP+VAN, confirming the results of previous literature. Chapter 3 presents a study of patients receiving VAN in combination with meropenem (MEM) or TZP. This study included over 10,000 patients and used inverse probability of treatment weighting to conserve data for this population. After controlling for confounders, VAN+TZP was associated with significantly more AKI than VAN+MEM. This study demonstrates that MEM is clinically viable alternative to TZP in empiric antimicrobial therapy. Chapter 4 describes a study in which patients receiving TZP or ampicillin-sulbactam (SAM) with or without VAN were analyzed for AKI incidence. The purpose of this study was to identify whether the addition of a beta-lactamase inhibitor to a beta-lactam increased the risk of AKI. This study included more than 2,400 patients receiving either agent and found that there were no differences in AKI among patients receiving SAM or TZP; however, AKI was significantly more common in the TZP group when stratified by VAN exposure. This study shows that comparisons of TZP to other beta-lactams without beta-lactamase inhibitors are valid. Chapter 5 presents a study of almost 30,000 patients who received combination antimicrobial therapy over an 8-year period. This study demonstrates similar AKI incidence to previous literature and the studies presented in the previous chapters. Additionally, the results of the predictive models suggest that further work in this research area is needed. The studies conducted present a clear message that patients receiving VAN+TZP are at significantly greater risk of AKI than alternative regimens for empiric coverage of infection.

Ineffective deployment of mobile technology jeopardizes healthcare quality, cost control, and access, resulting in healthcare organizations losing customers and revenue. A multiple case study was conducted to explore the strategies that chief information officers (CIOs) used for the effective deployment of mobile technology in healthcare organizations. The study population consisted of 3 healthcare CIOs and 2 healthcare information technology consultants who have experience in deploying mobile technology in a healthcare organization in the United States. The conceptual framework that grounded the study was Wallace and Iyer's health information technology value hierarchy. Data were collected using semistructured interviews and document reviews, followed by within-case and cross-case analyses for triangulation and data saturation. Key themes that emerged from data analysis included the application of disruptive technology in healthcare, ownership and management of mobile health equipment, and cybersecurity. The healthcare CIOs and consultants emphasized their concern about the lack of cybersecurity in mobile technology. CIOs were reluctant to deploy the bring-your-own-device strategy in their organizations. The implications of this study for positive social change include the potential for healthcare CIOs to emphasize the business practice of supporting healthcare providers in using secure mobile equipment deployment strategies to provide enhanced care, safety, peace of mind, convenience, and ease of access to patients while controlling costs.

Electronic health records (EHRs) facilitate storing, organizing, and sharing personal health information. The academic literature suggests that multimedia information (MM; image, audio, and video files) should be incorporated into EHRs. We examined the acceptability of MM-enabled EHRs for Ontario-based software vendors and physicians, using a qualitative analysis of primary and acute care EHR vendor websites, and a survey of physician perceptions regarding MM features in EHRs. Primary care EHR vendors provided more product-specific information than acute care vendors; however, neither group emphasized MM features in their EHRs. Physicians had slightly positive perceptions of image and video features, but not of audio features. None of the external factors studied predicted physicians‘ intention to use MM. Our findings suggest that neither vendors nor physicians are enthusiastic about implementing or using MM in EHRs, despite acknowledging potential benefits. Further research is needed to explore how to incorporate MM into EHR systems.