Doctor of Philosophy

dissertationClinical decision support (CDS) and electronic clinical quality measurement (eCQM) are 2 important computerized strategies aimed at improving the quality of healthcare. Unfortunately, computer-facilitated quality improvement faces many barriers. One problem area is the lack of integration of CDS and eCQM, which leads to duplicative efforts, inefficiencies, misalignment of CDS and eCQM implementations, and lack of appropriate automated feedback on clinicians' performance. Another obstacle in the acceptance of electronic interventions can be the inadequate accuracy of electronic phenotyping, which leads to alert fatigue and clinicians' mistrust of eCQM results. To address these 2 problems, the research pursued 3 primary aims: Aim 1. Explore beliefs and perceptions regarding the integration of CDS and eCQM functionality and activities within a healthcare organization. Aim 2. Evaluate and demonstrate feasibility of implementing quality measures using a CDS infrastructure. Aim 3. Assess and improve strategies for human validation of electronic phenotype evaluation results. To address Aim 1, a qualitative study based on interviews with domain experts was performed. Through semistructured in-depth and critical incident interviews, stakeholders' insights about CDS and eCQM integration were obtained. The experts identified multiple barriers to the integration of CDS and eCQM and offered advice for addressing those barriers, which the research team synthesized into 10 recommendations. To address Aim 2, the feasibility of using a standards-based CDS framework aligned with anticipated electronic health record (EHR) certification criteria to implement electronic quality measurement (QM) was evaluated. The CDS-QM framework was used to automate a complex national quality measure at an academic healthcare system which had previously relied on time-consuming manual chart abstractions. To address Aim 3, a randomized controlled study was conducted to evaluate whether electronic phenotyping results should be used to support manual chart review during single-reviewer electronic phenotyping validation. The accuracy, duration, and cost of manual chart review were evaluated with and without the availability of electronic phenotyping results, including relevant patient-specific details. Providing electronic phenotyping results was associated with improved overall accuracy of manual chart review and decreased review duration per test case. Overall, the findings informed new strategies for enhancing efficiency and accuracy of computer-facilitated quality improvement

Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research

Background: Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients (“feedback”) is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory. Methods: We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions. Results: We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback’s success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective. Conclusions: This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments

Front-Line Physicians' Satisfaction with Information Systems in Hospitals

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.Peer reviewe

On designing an algorithmically enhanced NHS: towards a conceptual model for the successful implementation of algorithmic clinical decision support software in the National Health Service

Established in 1948, the National Health Service (NHS) has lasted 75 years. It is, however, under considerable strain: facing chronic staff shortages; record numbers of emergency attendances; an ambulance wait-time crisis; and more. Increasingly, policymakers are of the view that the solution to these problems is to rely more heavily on one of the NHS’s greatest resources: its data. It is hoped that by combining the NHS’s data riches with the latest techniques in artificial intelligence (AI), that the means to make the NHS more effective, more efficient, and more consistent, can be identified and acted upon via the implementation of Algorithmic Clinical Decision Support Software (ACDSS). Yet, getting this implementation right will be both technically and ethically difficult. It will require a careful re-design of the NHS’s information infrastructure to ensure the implementation of ACDSS results in intended positive emergence (benefits), and not unintended negative emergence (harms and risks). This then is the purpose of my thesis. I seek to help policymakers with this re-design process by answering the research question ‘What are the information infrastructure requirements for the successful implementation of ACDSS in the NHS?’. I adopt a mixed-methods, theory-informed, and interpretive approach, and weave the results into a narrative policy synthesis. I start with an analysis of why current attempts to implement ACDSS into the NHS’s information infrastructure are failing and what needs to change to increase the chances of success; anticipate what might happen if these changes are not made; identify the exact requirements for bringing forth the changes; explain why the likelihood of these requirements being met by current policy is limited; and conclude by explaining how the likelihood of policy meeting the identified requirements can be increased by designing the ACDSS’s supporting information infrastructure around the core concepts of ‘utility, usability, efficacy, and trustworthiness’

Understanding the diagnostic process in a rare, genetic disease: a mixed methods study of schwannomatosis

Diagnostic errors are relatively common in medicine and can cause significant patient harm. We adapted the National Academy of Medicine’s model of the diagnostic process to examine diagnostic errors in schwannomatosis, a rare, genetic syndrome in which patients commonly develop multiple nerve sheath tumors and chronic pain. We specifically assessed how well the schwannomatosis diagnostic process currently functions; identified specific failures in the diagnostic process and assessed their contribution to diagnostic error; and explored the impact of diagnostic errors on patients’ lives. In study one, we reviewed the medical records of 97 schwannomatosis patients seen in two tertiary care clinics to assess the extent of diagnostic error in this population. It took a median of 7.9 years from patients’ first sign/symptom for a diagnosis of schwannomatosis to be established and communicated to patients. One-fifth of patients had a clear missed opportunity for appropriate workup that could have led to an earlier diagnosis. About one-third of patients experienced a misdiagnosis of their pain etiology, tumor pathology, or underlying genetic diagnosis. In study two, we created narrative summaries detailing patients’ diagnostic journeys using the medical record data of 52 schwannomatosis patients included in study one. Directed content analysis of these summaries identified the specific diagnostic process failures patients experience. Almost all patients experienced at least one failure, which most commonly reflected deficiencies in diagnostic testing, the clinical history/interview, or follow-up. Two-thirds of failures significantly impacted patient outcomes, most often by delaying needed diagnostic workup and communication of a final diagnosis to the patient. In study three, we interviewed 18 people with schwannomatosis from across the United States and used thematic analysis to explore patients’ symptom appraisal and the personal impact of diagnostic errors. Participants and their healthcare providers often ascribed schwannomatosis symptoms to more common conditions, which could delay care-seeking and initial workup. Diagnostic delay and misdiagnosis could result in unnecessary surgery, delayed receipt of effective pain management, psychological distress, and stigmatization. Collectively, these studies give unique insight into the prevalence, causes and ramifications of diagnostic error in schwannomatosis, and highlight opportunities to improve the diagnostic process across rare, genetic diseases

Impact Evaluations and Development: Nonie Guidance on Impact Evaluation

In international development, impact evaluation is principally concerned with final results of interventions (programs, projects, policy measures, reforms) on the welfare of communities, households, and individuals, including taxpayers and voters. Impact evaluation is one tool within the larger toolkit of monitoring and evaluation (including broad program evaluations, process evaluations, ex ante studies, etc.).The Network of Networks for Impact Evaluation (NONIE) was established in 2006 to foster more and better impact evaluations by its membership -- the evaluation networks of bilateral and multilateral organizations focusing on development issues, as well as networks of developing country evaluators. NONIE's member networks conduct a broad set of evaluations, examining issues such as project and strategy performance, institutional development, and aid effectiveness. By sharing methodological approaches and promoting learning by doing on impact evaluations, NONIE aims to promote the use of this more specific approach by its members within their larger portfolio of evaluations. This document, by Frans Leeuw and Jos Vaessen, has been developed to support this focus.For development practitioners, impact evaluations play a keyrole in the drive for better evidence on results and development effectiveness. They are particularly well suited to answer important questions about whether development interventions do or do not work, whether they make a difference, and how cost-effective they are. Consequently, they can help ensure that scarce resources are allocated where they can have the most developmental impact

Managerial and Entrepreneurial Decision Making

Since the conceptualization of bounded rationality, management scholars started investigating how people—managers and entrepreneurs—really make decisions within (and for) organizations. The aim of this eBook is to deeply investigate trends that have flourished within this pivotal research area in conceptual and/or empirical terms, trying to provide new insights on how managers and entrepreneurs make decisions within and for organizations. In this vein, readers that approach this eBook will be taken by hand and accompanied to the discovery of how the mind of decision makers is at the basis of organizational developments or failures. In this regard, published contributions in this eBook underline how executives and entrepreneurs must be ecologically rational, thus be aware of the negative and positive effects that biases can have depending on the context and use them at their advantage. Managerial and entrepreneurial decision-making are phenomena that cannot be detached from the environment in which executives and entrepreneurs are embedded, claiming to establish new approaches to research that looks at decision-making as an individual/group/organization-environment dialectical and multi-level phenomenon