DataGauge: A Model-Driven Framework for Systematically Assessing the Quality of Clinical Data for Secondary Use

There is growing interest in the reuse of clinical data for research and clinical healthcare quality improvement. However, direct analysis of clinical data sets can yield misleading results. Data Cleaning is often employed as a means to detect and fix data issues during analysis but this approach lacks of systematicity. Data Quality (DQ) assessments are a more thorough way of spotting threats to the validity of analytical results stemming from data repurposing. This is because DQ assessments aim to evaluate ‘fitness for purpose’. However, there is currently no systematic method to assess DQ for the secondary analysis of clinical data. In this dissertation I present DataGauge, a framework to address this gap in the state of the art. I begin by introducing the problem and its general significance to the field of biomedical and clinical informatics (Chapter 1). I then present a literature review that surveys current methods for the DQ assessment of repurposed clinical data and derive the features required to advance the state of the art (Chapter 2). In chapter 3 I present DataGauge, a model-driven framework for systematically assessing the quality of repurposed clinical data, which addresses current limitations in the state of the art. Chapter 4 describes the development of a guidance framework to ensure the systematicity of DQ assessment design. I then evaluate DataGauge’s ability to flag potential DQ issues in comparison to a systematic state of the art method. DataGauge was able to increase ten fold the number of potential DQ issues found over the systematic state of the art method. It identified more specific issues that were a direct threat to fitness for purpose, but also provided broader coverage of the clinical data types and knowledge domains involved in secondary analyses. DataGauge sets the groundwork for systematic and purpose-specific DQ assessments that fully integrate with secondary analysis workflows. It also promotes a team-based approach and the explicit definition of DQ requirements to support communication and transparent reporting of DQ results. Overall, this work provides tools that pave the way to a deeper understanding of repurposed clinical dataset limitations before analysis. It is also a first step towards the automation of purpose-specific DQ assessments for the secondary use of clinical data. Future work will consist of further development of these methods and validating them with research teams making secondary use of clinical data

Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

Doctor of Philosophy

DissertationHealth information technology (HIT) in conjunction with quality improvement (QI) methodologies can promote higher quality care at lower costs. Unfortunately, most inpatient hospital settings have been slow to adopt HIT and QI methodologies. Successful adoption requires close attention to workflow. Workflow is the sequence of tasks, processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Assessing the impact on workflow is an important component of determining whether a HIT implementation will be successful, but little research has been conducted on the impact of eMeasure (electronic performance measure) implementation on workflow. One solution to addressing implementation challenges such as the lack of attention to workflow is an implementation toolkit. An implementation toolkit is an assembly of instruments such as checklists, forms, and planning documents. We developed an initial eMeasure Implementation Toolkit for the heart failure (HF) eMeasure to allow QI and information technology (IT) professionals and their team to assess the impact of implementation on workflow. During the development phase of the toolkit, we undertook a literature review to determine the components of the toolkit. We conducted stakeholder interviews with HIT and QI key informants and subject matter experts (SMEs) at the US Department of Veteran Affairs (VA). Key informants provided a broad understanding about the context of workflow during eMeasure implementation. Based on snowball sampling, we also interviewed other SMEs based on the recommendations of the key informants who suggested tools and provided information essential to the toolkit development. The second phase involved evaluation of the toolkit for relevance and clarity, by experts in non-VA settings. The experts evaluated the sections of the toolkit that contained the tools, via a survey. The final toolkit provides a distinct set of resources and tools, which were iteratively developed during the research and available to users in a single source document. The research methodology provided a strong unified overarching implementation framework in the form of the Promoting Action on Research Implementation in Health Services (PARIHS) model in combination with a sociotechnical model of HIT that strengthened the overall design of the study

MS

thesisHealth information systems are networks of computers employed by health care enterprises to facilitate the delivery of their health care product. Computers originally entered the medical domain solely as tools aimed at the business functions of the hospital. Having demonstrated their utility in this area, computers were perceived by certain innovators to have usefulness in the clinical domain. As clinical computer applications were successfully developed and implemented, they have over time been merged together into systems offering multiple areas of functionality directly impacting the clinical aspects of health care delivery. Such health information systems have now assumed major importance in the provision of health care in a complex medical environment. Although the focus of substantial investment for development and implementation, relatively little work has been done to assess the value of such health information systems. The business information technology literature and the medical informatics literature each include only a small number of published reports examining the value question in an incomplete manner. No generally accepted valuation strategy has been developed for information systems in either the business or health care domains. Several valuation methods with potential applicability to health information systems have evolved: cost-effectiveness / cost- benefit analysis, return on investment, information economics, measurement systems, the Strassmann approach, the Japanese approach, and the strategic value approach. None of these valuation strategies is clearly superior; each has different strengths and weaknesses. A matrix comparing these strategies on the bases of explicitness and ease of implementation is proposed. Intermountain Health Care (IHC) has been instrumental in the development of health information systems and a leader in the application of such technology in clinical health care delivery. IHC's HELP system has played a seminal role as a catalyst to the development of the health information system industry. Although both historically and functionally important, detailed financial information regarding HELP'S origins and implementation no longer exists. Current IHC budget information demonstrates the major financial commitment underway within this health care enterprise totaling approximately $157 million over the last decade and with additional expenditures of$47 to $61 million projected annually through fiscal year 2004. The complex budgetary relationships between HELP and the other health information systems at LDS Hospital further obscure the magnitude of the information technology investment within this institution. Benefits of health information systems are potentially most substantial within the domain of clinical integration. IHC has not implemented any formal valuation strategy for its health information systems, but the ad hoc measurement systems valuation approach applied to date is practical, flexible, and the most appropriate of the available systems. Adequate valuation of health information systems cannot readily be achieved given the existing traditional hierarchical accounting structure; an alternative accounting framework patterned after a relational database is proposed

Health care service quality and patients' satisfaction under dual-capital operations mode: the case of Shanghai General Hospital

The dual capital operation mode of Chinese public hospitals studied in this thesis is the combination of two state-owned capitals. However, few studies have provided valid evidence that dual capital has stronger advantages than single capital in hospital operation. Based on the perspective of interactive memory, a link moderation model is proposed in this thesis. The model links the independent and dependent variables via the two mediating variables. In this study, we argue that the hospital's dual capital operation model is helpful in increasing the team collaboration of physicians compared to the single capital operation model. And the team collaboration helps to improve the quality of medical services, which in turn helps to promote patient satisfaction. Therefore, this study concludes that the dual capital operation model can enhance patient satisfaction via the mediating role of team coordination and medical service quality. In addition, this thesis further demonstrates the role of a dual capital operation model for hospital service quality improvement through a case study. We believe that the conclusion provides a theoretical support to demonstrate the effectiveness of a dual capital operation system in hospitals. In the future reform of the hospital operation system, we suggest that public hospitals in China introduce other capital to further drive high quality development.O sistema dual capital operation mode em hospitais públicos abordado nesta tese é a combinação de dois tipos de capitais públicos. No entanto, são poucos os estudos que têm investigado as vantagens que este sistema tem sobre um sistema de single capital operation mode em contexto hospitalar. Com base na perspetiva da memória interativa, nesta tese é proposto um modelo com efeitos mediadores. O modelo relaciona as variáveis independentes e dependentes por meio das duas variáveis mediadoras. Neste estudo, é avaliada a utilidade que um sistema dual capital operation mode em contexto hospitalar tem na melhoria da colaboração da equipa de médicos em comparação com um sistema de single capital operation mode. Por sua vez, a colaboração da equipa médica ajuda a melhorar a qualidade dos serviços médicos, o que por sua vez ajuda a promover a satisfação dos pacientes. Portanto, este estudo conclui que um sistema dual capital operation mode pode aumentar a satisfação dos pacientes através do papel mediador da colaboração da equipa médica e da qualidade do serviço prestado. Além disso, esta tese mostra o papel que um sistema dual capital operation mode tem na melhoria da qualidade do serviço hospitalar num estudo de caso concreto. A conclusão fornece um suporte teórico para demonstrar a eficácia de um sistema dual capital operation mode em hospitais. Numa futura reforma do sistema hospitalar na China, sugerimos que sejam introduzidas outras formas de capital para impulsionar ainda mais um desenvolvimento de elevada qualidade

Generational advancement in sovereign nations: a qualitative study understanding the significance of knowledge infrastructure

Throughout history, socio-cultural and political movements have condemned indigenous peoples by advancing false rhetoric, half-truths, and equivocations championed as axiomatic principles. Foreign entities have massacred philosophies, traditions, and tribes while stealing ancestral lands that have yet to be recovered. This exploratory study examines the phenomenon of developing knowledge infrastructure within sovereign nations. A descriptive qualitative approach was used to answer the research question: To what extent, if at all, might knowledge infrastructure support generational advancement through learning and development programs within sovereign nations? Semi-structured interviews were conducted with 15 Tribal citizens, community members, and employees who currently or have worked in business enterprises within sovereign nations in the United States. This study details the significance of knowledge infrastructure and proposes recommendations based on collective voices within sovereign nations

Promotion and Marketing Communications

This edited Promotion and Marketing Communications book is an original volume that presents a collection of chapters authored by various researchers and edited by marketing communication professionals. To survive in the competitive world, companies feel an urge to achieve a competitive advantage by applying accurate marketing communication tactics. Understanding marketing communication is an essential aspect for any field and any country. Hence, in this volume there is the latest research about marketing communication under which marketing strategies are delicately discussed. This book does not only contribute to the marketing and marketing communication intellectuals but also serves different sector company managerial positions and provides a guideline for people who want to attain a career in this field, giving them a chance to acquire the knowledge regarding consumer behavior, public relations, and digital marketing themes

Three Essays on the Enterprise Strategy for Multinational Firms

The enterprise strategy (ES) of the firm is the overarching organizational strategy which reflects the firm\u27s degree of integration with society. It asks, What do we stand for? Very little is known about the ES; however, it is an important construct which can deepen our understanding of the stakeholder management process and the firm\u27s long-term performance. Unlike much previous ES research, this three-essay dissertation examines both the nature of and the antecedents for ES in a cross-national setting. The introductory essay offers a conceptual model describing the organizational identity orientation effects on the multinational enterprise\u27s (MNE) ES. Additionally, it shows the interactive effects between the organizational identity orientation and the institutional identity orientation on the ES. The second essay utilizes the two theoretically-suggested dimensions of the ES—scope and type—to develop an ES measure. A computer-aided text analysis of 439 stakeholder letters of multinational and US firms revealed the presence of ES language. A reliable and valid ES measure was then constructed. A subsequent analysis produced ES configurations which broadly align with the four ideal ES types of Meznar, Chrisman, and Carroll (1991)—Narrow Defensive, Narrow Offensive, Broad Defensive and Broad Offensive. This research is extended in a third essay examining the impact of the diversity in the MNE\u27s environment on the ES. Using a multi-level analysis, this study first explores the effects of the top management team\u27s (TMT) and the board of directors\u27 (BOD) gender diversity, the TMT functional diversity, and the BOD\u27s stakeholder representation on the levels of the ES integration of 287 MNEs from 30 countries in 2011. The moderating effects on the above relationships emerging from the political culture of an MNE\u27s home country are also tested. According to the findings, gender diversity in the upper echelons positively influences the level of ES integration. This relationship is moderated by the political culture of the home country. The BOD stakeholder representation also positively influences the level of ES integration, but this relationship is not influenced by the MNE\u27s home-country political culture. Finally, the relationship between the top management team functional diversity and the dependent variable is not significant

Implementation of an Innovative Early Warning System: Evidenced-based Strategies for Ensuring System-wide Nursing Adoption

Early deterioration in adult medical-surgical patients is associated with increased intensive care unit and hospital mortality (Goldhill, 2001). Failure to recognize deterioration is a preventable patient safety and quality issue. To address this problem, since 2013, Kaiser Permanente Northern California (KP NCAL) has piloted Advance Alert Monitor (AAM) at two hospitals. This early warning system employs a set of predictive models developed by the KP NCAL Division of Research, which automatically predicts patient deterioration within the next 12 hours based on a complex algorithm of laboratory and clinical data points. Improvements in mortality and length of stay have been realized at the two pilot hospitals. In anticipation of expansion to additional NCAL facilities, major changes to the AAM workflows and processes were developed that increased the sensitivity of the patients identified at risk for clinical deterioration, as well as the timeliness and clarity of clinical response. Expansion to two additional pilot hospitals using these revised processes rely on the evidence-based implementation strategies found in this Doctor of Nursing Practice project. This paper examines the planning, assessment, and implementation of early warning systems at two NCAL facilities using Rogers’ diffusion of innovation theory and Greenhalgh’s extension of Rogers’ theory. Key attributes need to be considered from a cultural and organizational perspective to both start and sustain an implementation. The success of AAM implementation is validated using specific outcome and process measures, including compliance with documentation and timeliness of workflows

Servant Leadership Characteristics and Empathic Care: Developing a Culture of Empathy in the Healthcare Setting

The purpose of this study was to assess the degree to which servant leadership characteristics are exhibited in medical group practices, and the degree to which servant leadership characteristics correlated with measures of empathic care. This study featured an explanatory mixed methods research design embedded in appreciative inquiry. A total of 189 mid-level practitioners consisting of nurse practitioners, physician assistants, and practice mangers responded to a 32-item scale survey that featured a six-point Likert scale to measure servant leadership items and a 10-point continuous scale to assess measures of empathic care. The servant leadership items were based on the seven pillars of servant leadership. Data analyses included assessing means, standard deviations, and percentage distributions for servant leadership statements and empathic care statements. Additionally, bivariate correlation analysis and standard multiple regression analysis were conducted to assess the degree of influence of servant leadership characteristics on measures of empathic care. Findings from this study identified Pillar 1 (Persons of Character) as the servant leadership pillar most strongly exhibited in the medical group practices. Furthermore, Pillar 5 (Has Foresight) was the strongest correlate of reported empathic care within medical group practices as well as team members’ proclivity to practice servant leadership behaviors with patients more than with each other. The study also found that clinicians and non-clinicians significantly differed in their endorsement of all of the servant leadership pillars except Pillar 1 (Persons of Character). The findings of this dissertation point to strategies for promoting an environment of empathic care, and team building and organizational development and training in the medical group practices. This dissertation is available in open access at AURA: Antioch University Repository and Archive, http://aura.antioch.edu/ and OhioLINK ETD Center, https://etd.ohiolink.edu