DEPLOYED ELECTRONIC MEDICAL RECORD POLICY COMPLIANCE: AN INTRA-DEPARTMENT PRINCIPAL-AGENT PERSPECTIVE

To understand problems related to a policy of implementing a lifelong longitudinal electronic health record (EHR) more fully, this dissertation examines compliance with changes in policy over time. We analyze drivers of compliance with a required electronic medical record (EMR) by hospital clinicians completing the records for deployed service members. This study examines compliance as an outcome of principal-agent (PA) relationships, with the EMR modeled as the measure of success between one level of bureaucratic principal (i.e. medical command) with control over the necessary mechanisms in order to ensure compliance of agents (i.e., medical professionals). Policy compliance is operationalized in three ways: 1) the total number of inpatient EMRs completed; 2) the date on which new records are started; 3) the average number of days to close an inpatient EMR. For each of these dimensions, \u27EMR\u27 refers to what clinicians categorize as treatment for a disease non-battle injury or battle injury. The first independent variable concept for this study is change in the level of information asymmetry between principal and agent, operationalized as the time a superordinate medical command (MEDCOM) is directly in control over hospitals. The second concept is the alignment of goals in order to reduce goal conflict. This is operationalized as a technology upgrade allowing hospital EMR to be used for both implementing the larger EHR as well as in providing real-time clinical notes necessary for the care of patients being evacuated to the next level of medical care. Finally, the concept of principal control mechanisms are operationalized in this study as the introduction of increased monitoring policy and sanctions at the clinician level during hospital transition periods. We use quantitative data in the form of completed electronic medical records and utilize a quasi-experimental research design. The specific design chosen for the study is the interrupted time-series. The population for this study is all United States military service members seen as inpatients in deployed military hospitals directly supporting Operation Iraqi Freedom. The study period is 105 weeks. Overall, this research meets the objectives outlined in Chapter 1 (Introduction). The study examined two important questions regarding clinician compliance with completing EMRs for deployed service members. First, this study addressed if there was a change in policy compliance over time. By conducting an analysis of policy interventions, we established changes in policy compliance. Compliance was defined as the fluctuation in inpatient records started, records completed, and changes in the average time to complete records. Secondly, this study examined what factors influenced the performance of hospital clinicians and how significant these drivers\u27 impact was on record completion. The analysis consisted of graphing the changes over time and examining changes that were most likely due to policy interventions. We further analyzed the changes over time utilizing ANOVA and least squares regression. The results supported many of the hypotheses. Technology upgrades not only led to greater completion rates but also reduced the amount of variation in records completed week to week. The introduction of the monitoring policy also increased both record completions and records started. Finally, sanctioning showed the greatest impact on completing records. This research is important for four reasons. First, this study provides a method to analyze policy implementation at different levels within one federal department. Second, this research enhances the body of knowledge in the inter-disciplinary evaluation of policy implementation. Third, this dissertation examines the role of specific control mechanisms, namely monitoring and sanction, not previously reported in the EHR implementation literature. Finally, this study provides real-world implications for implementing EHR policies in deployed environments. This study determines that the time a MEDCOM is in charge, technology upgrades, monitoring, and sanctions do have an effect on policy compliance but are reliant on the measurement of compliance. As an example, technology upgrades significantly increase the number of EMR completed at hospitals, but they are not statistically significant in increasing or decreasing the number of new encounters started at the hospital. In addition, patient categories influence the significance between the independent and dependent variables

IMPACT OF TECHNOLOGY ON IMPROVING HIV AND TUBERCULOSIS HEALTH OUTCOMES AMONG AFRICAN COUNTRIES

This study used health analytics approach to evaluate the association between population health outcomes and Information and Communication Technology (ICT) infrastructures at a country level. This study used aggregate data obtained from the World Bank database, and the International Telecommunication Union (ITU) database for 53 African countries for the periods 2000 to 2016, and quantitatively explored the impact of ICT infrastructures’ diffusion on population health outcomes. ICT data was obtained from the ITU database. Similarly, population health attributes were retrieved from the World Bank database. ICT infrastructure variables used in this study include: internet access, mobile phone use, and fixed telephone subscriptions. However, population health outcome variables for this study include: HIV prevalence, access to antiretroviral therapy, Tuberculosis incidence, and mortality rates. Econometric study methodology involved a Dynamic Panel Model (DPM). Study findings showed that promoting ICT use among the public has opportunities for improving Tuberculosis (TB) and HIV health outcomes. However, the impact of each ICT infrastructures on improving TB and HIV health outcomes differed, which this study inferred to be as a result of different functionalities of the ICT infrastructures, as well as the peculiar features of the health outcomes studied. This study also did an Exploratory Spatial Data Analysis (ESDA) of TB treatment completion rates among health systems in Africa to help visualize trends and identify patterns, clusters and outliers. It evaluated spatial relationships between mobile phone use and TB treatment completion rates using differential local Moran’s I and bivariate Moran’s I techniques. Study result identified statistically significant positive autocorrelation values for the periods evaluated, as well as varying cluster patterns in TB treatment completion rates. The cluster patterns increased across the three-time periods among geographically referenced data evaluated in this study. This study also identified a direct relationship between mobile phone use and TB treatment completion rates among relevant African countries studied. Thereby, necessitating the need to strengthen national policies that promote TB and HIV medication adherence and completion using eHealth strategies among African health systems. Another important policy implication of this study for African governments is that investing in eHealth, including educating the masses on ICT use, could be an alternative policy to improve population health

Using Dooyeweerd's aspects to understand down to earth issues in use of medical records

This research is about experience of using electronic medical records (EMR). Chapter 1introduces and justifies the main research question “How can Down To Earth issues that areimportant in uses of EMR be studied by using Dooyeweerd's aspects?” Down To Earth (DTE) issues are those meaningful in daily uses of patient medical recordsrather than those meaningful for management, ICT suppliers and academics. A survey of the literature (Chapter 2) reveals that high level issues rather than DTE issues aremostly discussed. Even where the literature mentions DTE issues, there is a need for threeresearch activities1-reveal DTE issues to bring to light those which are significant and important2-uncover the hidden issues and the reasons for these hidden issues.3-classify the issues to identify which of these are the most significant After considering a range Information Systems (IS) Theories, Dooyeweerd’s aspects emergedas a suitable theoretical framework to reveal, uncover and classify DTE issues (Chapter 3).Interpretivism was the philosophical lens of choice given that it primarily seeks meaning andinsights, much in keeping with this research which looks for the meaningful issues ofMedical Record (MR) users and aims to gain insights into DTE issues of MR uses. So aninterpretive approach is used (Chapter 4). Users of MR are interviewed and Dooyeweerd’saspects are employed to analyse the transcripts and a selection of excerpts from papers(Chapter 5). Using the results of aspectual analysis of these texts, five quantitative and qualitativecomparisons are made of the following (Chapter.6) The comparison of hospitalsThe comparison of paper and electronic records.The comparison of nursesThe comparison of nationalitiesThe research has three main findings (Chapter 7). 1-The meaningful DTE issues for medical record users are different from the meaningfulissues discussed in the literature. 2-Aspectual analysis enables us to reveal, uncover and classify DTE issues that aremeaningful for medical record users. 3- Each type of user tends to have a unique aspectual profile.Chapter.8 discusses limitations of the research and how this research might contribute topractice methodology and theory. The research contributes to practice of designing andevaluating EMR systems. Furthermore the research could help to generate a theory ofmedical records. Also the research offers a method for analysing DTE issues for otherresearchers in other sectors

Lernende als Designer: Untersuchungen zum Alltagsdesign in der Lerntätigkeit

Lernende sind zunehmend herausgefordert ihren Lernprozess selbstständig zu steuern, zu organisieren und zu gestalten. Die vorliegende Arbeit geht von diesen Erwartungen aus und fragt nach den kreativen Prozessen in der Lerntätigkeit. Dazu wird eine kritische Prüfung von Lerntheorien hinsichtlich ihrer Berücksichtigung von Kreativität und Materialität unternommen. Durch Entwicklung eines Designbegriffs, der die scheinbar selbstverständlichen Techniken und Strategien im Lernalltag als Alltagsdesign erfasst, wird ein wenig berücksichtigtes Forschungsgebiet eröffnet, das in qualitativen Untersuchungen medienübergreifend analysiert wird. Die verschiedenen Aspekte des Alltags­designs in der Lerntätigkeit – die Einrichtung des Arbeitsplatzes, das Aufgabenmanagement, die Aufbewahrung und die Verarbeitung von Lernmaterial werden detailliert beschrieben und analysiert. Resultat ist eine gegenstandsbezogene Theorie des Alltags­designs in der Lerntätigkeit, die einen Beitrag zum Verständnis von Wissensarbeit als materiale Praxis liefert.This thesis is a contribution to current debates about technology enhanced learning – namely “web 2.0” and “e-learning 2.0” where learners are expected to be active creators of knowledge. The figure of the learner as creative designer is addressed in this work, which concentrates on learners’ individual activity. The focus on the individual contrasts with many current studies about learning which center on collaborative aspects in knowledge building. First a review of learning theories is undertaken to examine their contributions to questions of materiality and creativity in learning activities. Turning to design research, a notion of design as practice is developed, which here complements and enhances current learning theories. Adopting notions of “use” and “user” the everydayness of design is reconstructed, leading to a conceptualization which is suitable to everyday activities of learners. From this everyday design perspective, the research question is formulated: How is learning activity accomplished as design activity? This question is tackled through several ethnographically oriented studies that focus on the individual everyday practices of students in their natural working environments. The analysis of the ethnographic data is developed using a Grounded Theory approach. A descriptive story is developed that analyzes arrangements of workplaces and objects, storage and task management, and the production of personal learning material as design. From these concepts four core aspects of everyday design in learning activities are developed: The design of the environment, “becoming designed”, designing oneself, and designing the design process. A model of the everyday design process is proposed which reveals both its creative and persistent side. The notion of everyday design in learning activities is an important concept to understand learners’ difficulties in knowledge building and to advance the development of learning strategies