Interfacing Health Care Information Systems Design and Implementation

Terveydenhuollossa käytetään nykyisin informaatioteknologian (IT) mahdollisuuksia parantamaan hoidon laatua, vähentämään hoitoon liittyviä kuluja sekä yksinkertaistamaan ja selkeyttämään laakareiden työnkulkua. Tietojärjestelmät, jotka edustavat jokaisen IT-ratkaisun ydintä, täytyy kehittää täyttämään lukuisia vaatimuksia, ja yksi niistä on kyky integroitua saumattomasti toisten tietojärjestelmien kanssa. Järjestelmäintegraatio on kuitenkin yhä haastava tehtävä, vaikka sita varten on kehitetty useita standardeja. Tässä työssä kuvataan vastakehitetyn lääketieteellisen tietojärjestelmän liittymäratkaisu. Työssä pohditaan vaatimuksia, jotka tällaiselle sovellukselle asetetaan, ja myös tapa, jolla vaatimukset toteutuvat on esitetty. Liittymaratkaisu on jaettu kahteen osaan, tietojärjestelmaliittymään ja "liittymakoneeseen" (interfacing engine). Edellinen on käsittää perustoiminnallisuuden, jota tarvitaan vastaanottamaan ja lähettämään tietoa toisiin järjestelmiin, kun taas jälkimmäinen tarjoaa tuen tuotantoympäristössa käytettäville standardeille. Molempien osien suunnitelu on esitelty perusteellisesti tässä työssä. Ongelma ratkaistiin modulaarisen ja geneerisen suunnittelun avulla. Tämä lähestymistapa osoitetaan työssä kestäväksi ja joustavaksi ratkaisuksi, jota voidaan käyttää tarkastelemaan laajaa valikoimaa liittymäratkaisulle asetettuja vaatimuksia. Lisaksi osoitetaan kuinka tehty ratkaisu voidaan joustavuutensa ansiosta helposti mukauttaa vaatimuksiin, joita ei ole etukäteen tunnistettu, ja siten saavutetaan perusta myös tulevaisuuden tarpeille

Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.

Co-evolution of Policy Sectors: Health Care and Public Health in five Countries

Cette thèse analyse la co-évolution de deux secteurs dans la politique de la santé: santé publique (public health) et soins aux malades (health care). En d'autres termes, la relation entre les dimensions curative et préventive de la politique de la santé et leur développement dans la durée. Une telle recherche est nécessaire car les problèmes de la santé sont complexes et ont besoin de solutions coordonnées. De plus, les dépenses de la santé ont augmenté sans arrt durant les dernières décennies. Un moyen de réduire une future augmentation des dépenses pourrait consister en davantage d'investissement dans des mesures préventives. En relation avec cette idée, ma recherche analyse les politiques de la santé publique et les soins aux malades de cinq pays: Allemagne, Angleterre, Australie, Etats-Unis et Suisse. En m'appuyant sur la littérature secondaire, des statistiques descriptives et des entretiens avec des experts et des politiciens, j'analyse la relation entre les deux secteurs depuis la fin du dix-neuvième siècle. En particulier, je me focalise sur la relation des deux champs sur trois niveaux: institutions, acteurs et politiques. Mes résultats montrent les similitudes et les différences d'évolution entre les cinq pays. D'un c^oté, lorsque la profession médicale est politiquement active et que le pays consiste en une fédération centralisée ou en un gouvernement unitaire, les deux secteurs sont intégrés au niveau institutionnel, ralliant les professions et groupes d'intérêt des deux secteurs la cause commune dans une activité politique. Par contre, dans tous les pays, les deux secteurs ont co-évolué vers une complémentarité malgré de la politisation des professions et la centralisation du gouvernement. Ces résultats sont intéressants pour la science politique en général car ils soulignent l'importance des professions pour le développement institutionnel et proposent un cadre pour l'analyse de la co-évolution des politiques publiques en général. -- This Ph.D. thesis analyzes the co-evolution of the health care and the public health sectors. In other words, the relation between preventive and curative health policy and its evolution over time. Such research is necessary, because current health problems are complex and might need coordinated solutions. What is more, health expenditures have increased continuously in the last decades. One way to slow down further increase in health spending could be to invest more in preventative health policies. Therefore, I am connecting individual health care and public health into a common analysis, taking Australia, Germany, Switzerland, the UK and the U.S. as examples. Based on secondary literature, descriptive statistics and interviews with experts and policymakers, I am analyzing how the two sectors' relations co-evolved between the late nineteenth and the early twenty-first century. Specifically, I am researching how health care and public health were related on the levels of institutions, actors and policies. My results show that there are differences and similarities in the co-evolution of policy sectors between these countries. On the one hand, when the medical profession was politically active and the country a centralized federation or a unitary state, there was institutional integration and common political advocacy of the sectors' interest groups and professions. On the other hand, in all countries, both sectors co-evolved towards complementarity, irrespectively of the politicization of professions and centralization of government. These findings are interesting for the political science literature at large, because they underline the importance of professions for institutional development and propose an analytical framework for analyzing the co-evolution of policy sectors in general.

Multimorbidity in primary care : protocol of a national cross-sectional study in Switzerland.

INTRODUCTION: With the ageing of the population and the general improvement of care, an increasing number of people are living with multiple chronic health conditions or 'multimorbidity'. Multimorbidity often implies multiple medical treatments. As a consequence, the risk of adverse events and the time spent by patients for their treatments increase exponentially. In many cases, treatment guidelines traditionally defined for single conditions are not easily applicable. Primary care for individuals with multimorbidity requires complex patient-centred care and good communication between the patient and the general practitioner (GP). This often includes prioritising among the different chronic conditions. METHODS AND ANALYSIS: The main objectives of this study are to describe the burden related to multimorbidity (disease-related burden and burden of treatment) in primary care and to identify the factors influencing it. Other objectives include evaluating patients' perception of treatment burden and quality of life, assessing factors influencing that perception, and investigating prioritisation in the management of multimorbidity from the perspectives of GPs and patients. For this cross-sectional study, patient enrolment will take place in GP's private practices across Switzerland. A convenient sample of 100 GPs will participate; overall, 1000 patients with at least three chronic health conditions will be enrolled. Data will be collected as paper-based questionnaires for GPs and delayed telephone interview questionnaires for patients. GPs will provide demographic and practice-related data. In addition, each GP will complete a paper-based questionnaire for each patient that they enrol. Each patient will complete a telephone interview questionnaire. ETHICS AND DISSEMINATION: This study has been approved by the research ethics committee of Canton Vaud, Switzerland (Protocol 315/14). The results of the study will be reported in international peer-reviewed journals.

Patient-centered Care in Maternity Services: A Critical Appraisal and Synthesis of the Literature.

BACKGROUND: Patient-centered care (PCC) has been recognized as a marker of quality in health service delivery. In policy documents, PCC is often used interchangeably with other models of care. There is a wide literature about PCC, but there is a lack of evidence about which model is the most appropriate for maternity services specifically. AIM: We sought to identify and critically appraise the literature to identify which definition of PCC is most relevant for maternity services. METHODS: The four-step approach used to identify definitions of PCC was to 1) search electronic databases using key terms (1995-2011), 2) cross-reference key papers, 3) search of specific journals, and 4) search the grey literature. Four papers and two books met our inclusion criteria. ANALYSIS: A four-criteria critical appraisal tool developed for the review was used to appraise the papers and books. MAIN RESULTS: From the six identified definitions, the Shaller's definition met the majority of the four criteria outlined and seems to be the most relevant to maternity services because it includes physiologic conditions as well as pathology, psychological aspects, a nonmedical approach to care, the greater involvement of family and friends, and strategies to implement PCC. CONCLUSION: This review highlights Shaller's definitions of PCC as the one that would be the most inclusive of all women using maternity services. Future research should concentrate on evaluating programs that support PCC in maternity services, and testing/validating this model of care.

Satisfaction with pregnancy and delivery services: The quality of maternity care services as experienced by women

Objective: The objective of this study was to investigate the opinions of women regarding the satisfaction about the quality of maternity care received. We hope to establish whether health care technology increases satisfaction or whether it actually interferes with the construction of personal satisfaction in the process of care. Design and setting: Information was gathered using the focus group technique. The area of study comprised the post-natal groups run as part of the Sexual and Reproductive Health Programme of the Catalan Health Authority. (Spain) Participants: Five focus groups were held between May 2006 and July 2007. Findings: Quality of care is a complex concept in which a number of independent core features can be identified. We have grouped these core features into three basic categories. Safety: the hospital and its technological facilities, and the technical expertise of health professionals. The other two main pillars of quality of care are the human dimension of the relationship between the carers and the patient, and finally the structural aspects that determine the context in which the heath care is provided. Key conclusions and implications for practice: The mothers of our study feel satisfied with healthcare technology and view it as a source of security; technology become indispensable features in order to reduce the anxiety provoked by the perceived lack of confidence in their ability as mothers. In this study, women, both during pregnancy and especially when giving birth, believe their feelings and values should be understood by professionals, from whom they seek empathy and a personal commitment, and not just information.

Satisfaction with pregnancy and delivery services: The quality of maternity care services as experienced by women

Objective: The objective of this study was to investigate the opinions of women regarding the satisfaction about the quality of maternity care received. We hope to establish whether health care technology increases satisfaction or whether it actually interferes with the construction of personal satisfaction in the process of care. Design and setting: Information was gathered using the focus group technique. The area of study comprised the post-natal groups run as part of the Sexual and Reproductive Health Programme of the Catalan Health Authority. (Spain) Participants: Five focus groups were held between May 2006 and July 2007. Findings: Quality of care is a complex concept in which a number of independent core features can be identified. We have grouped these core features into three basic categories. Safety: the hospital and its technological facilities, and the technical expertise of health professionals. The other two main pillars of quality of care are the human dimension of the relationship between the carers and the patient, and finally the structural aspects that determine the context in which the heath care is provided. Key conclusions and implications for practice: The mothers of our study feel satisfied with healthcare technology and view it as a source of security; technology become indispensable features in order to reduce the anxiety provoked by the perceived lack of confidence in their ability as mothers. In this study, women, both during pregnancy and especially when giving birth, believe their feelings and values should be understood by professionals, from whom they seek empathy and a personal commitment, and not just information.

Le sentiment de gratitude en soins palliatifs : un facteur contribuant au bien-être et à la qualité de vie ? [Gratitude in palliative care: is it a psychological factor contributing to well-being and quality of life?]

En s'appuyant sur la littérature scientifique et l'état de la recherche, cet article a pour objectif de montrer pourquoi la prise en compte du sentiment de gratitude peut s'avérer utile dans le contexte palliatif en mettant en évidence dans quelle mesure cette émotion ou disposition individuelle: 1) entre en résonance avec le concept de croissance posttraumatique et certains enjeux relationnels chez les patients en fin de vie; 2) représente un facteur favorisant le bien-être et la qualité de vie; 3) peut être considérée comme un facteur protecteur contre les troubles psychopathologiques. Based on the scientific literature and the state of research, this article aims to show why the feeling of gratitude may represent a point of interest for palliative care. We will highlight the following in this article: 1) why this feeling of gratitude resonates with the concept of post-traumatic growth and relational challenges in end-of-life patients; 2) in which measure this feeling represents a factor contributing to well-being and quality of life; 3) in which measure this feeling may be considered as a protective factor against psychopathological troubles.

Health care utilization among immigrants and native-born populations in 11 European countries. Results from the Survey of Health, Ageing and Retirement in Europe

This study examines health care utilization of immigrants relative to the native-born populations aged 50 years and older in eleven European countries. Methods. We analyzed data from the Survey of Health Aging and Retirement in Europe (SHARE) from 2004 for a sample of 27,444 individuals in 11 European countries. Negative Binomial regression was conducted to examine the difference in number of doctor visits, visits to General Practitioners (GPs), and hospital stays between immigrants and the native-born individuals. Results: We find evidence those immigrants above age 50 use health services on average more than the native-born populations with the same characteristics. Our models show immigrants have between 6% and 27% more expected visits to the doctor, GP or hospital stays when compared to native-born populations in a number of European countries. Discussion: Elderly immigrant populations might be using health services more intensively due to cultural reasons.

The Quality of Paediatric Nursing Care - Children’s Perspective

Hoitotyön laatu - lasten näkökulma Tämän kolmivaiheisen tutkimuksen tarkoituksena oli kuvailla lasten odotuksia ja arviointeja lasten hoitotyön laadusta sekä kehittää mittari kouluikäisille sairaalassa oleville lapsille laadun arviointiin. Perimmäisenä tavoitteena oli lasten hoitotyön laadun kehittäminen sairaalassa. Ensimmäisessä vaiheessa 20 alle kouluikäistä (4-6v) sekä 20 kouluikäistä (7-11v) lasta kuvailivat odotuksiaan lasten hoitotyön laadusta. Aineisto kerättiin haastattelulla ja lasten piirustusten avulla, sekä analysoitiin sisällön analyysilla. Lasten odotukset lasten hoitotyön laadusta kohdistuivat hoitajaan, hoitotyön toimintoihin ja ympäristöön, fyysinen ympäristö korostui piirustuksissa. Ensimmäisen vaiheen tulosten, aikaisemman kirjallisuuden sekä Leino-Kilven “HYVÄ HOITO” mittarin pohjalta kehitettiin “Lasten Hoidon Laatu Sairaalassa” (LHLS) mittari ja testattiin sen psykometrisiä ominaisuuksia tutkimuksen toisessa vaiheessa. Mittaria kehitettiin ja testattiin kolmen vaiheen kautta. Aluksi asiantuntijapaneeli (n=7) arvioi mittarin sisältöä. Seuraavaksi mittari esitestattiin kahdesti kouluikäisillä sairaalassa olevilla lapsilla (n=41 ja n=16), samassa vaiheessa myös viiden lastenosaston hoitajat (n=19) yhdessä arvioivat mittarin sisältöä sekä 8 lasta. Lopuksi mittaria testattiin kouluikäisillä lapsilla (n=388) sairaalassa sekä hoitajat (n=198) arvioivat mittarin sisällön validiteettia. Mittarin kehittämisen aikana päälaatuluokkien: hoitajan ominaisuudet, hoitotyön toiminnot ja hoitotyön ympäristö Cronbachin alfa kertoimet paranivat. Pääkomponentti analyysi tuki mittarin hoitotyön toimintojen ja ympäristön alaluokkien teoreettista rakennetta. Kolmannessa vaiheessa “Lasten Hoidon Laatu Sairaalassa” (LHLS III, versio neljä) mittarilla kerättiin aineisto Suomen yliopistosairaaloiden lastenosastoilta kouluikäisiltä 7-11 -vuotiailta lapsilta (n=388). Mittarin lopussa lapsia pyydettiin lisäksi kuvailemaan kivointa ja ikävintä kokemustaan sairaalahoidon aikana lauseen täydennystehtävänä. Aineisto analysoitiin tilastollisesti sekä sisällön analyysilla. Lapset arvioivat fyysisen hoitoympäristön, hoitajien inhimillisyyden ja luotettavuuden sekä huolenpidon ja vuorovaikutustoiminnot kiitettäviksi. Lapset arvioivat hoitajien viihdyttämistoiminnot kaikkein alhaisimmiksi. Lapsen ikä ja sairaalantulotapa olivat yhteydessä lasten saamaan tiedon määrään. Lasten kivoimmat kokemukset liittyivät ihmisiin ja heidän ominaisuuksiinsa, toimintoihin, ympäristöön sekä lopputuloksiin. Ikävimmät kokemukset liittyivät potilaana oloon, tuntemuksiin sairauden oireista sekä erossaoloon, hoitotyön fyysisiin toimintoihin sekä ympäristöön. Tutkimuksen tulokset osoittavat lasten olevan kykeneviä arvioimaan omaa hoitoaan ja heidän näkökulmansa tulisi nähdä osana koko laadun kehittämisprosessia parannettaessa laatua käytännössä todella lapsilähtöisemmällä lähestymistavalla. “Lasten Hoidon Laatu Sairaalassa” (LHLS) mittari on mahdollinen väline saada tietoa lasten arvioinneista lasten hoitotyön laadusta, mutta mittarin testaamista tulisi jatkaa tulevaisuudessa

Exploring Customer-Oriented Service Offerings in Public Health: Developing Integrated Health Care Services for Rural Areas

Väestön ikääntyminen pakottaa yhteiskunnan ja julkisen terveydenhuollon muutoksiin. Jotta ikääntyvien ihmisten kotona asuminen voidaan mahdollistaa, palvelujärjestelmän pitää mukautua muuttuvaan tilanteeseen. Tämän diplomityön tarkoituksena on tunnistaa asiakaslähtöisiä lähellä asiakasta tarjottavia palvelukokonaisuuksia. Tutkimuksen teoreettinen viitekehys muodostuu asiakasarvon luomisesta ja palvelutarjoamista. Tarkasteluryhmänä on Etelä-Karjalan alueen 60–90-vuotiaat ja käytetty aineisto on kerätty vastaajilta postitse lähetetyllä kyselyllä. Tutkimus on eksploratiivinen ja tulosten tulkinnassa on hyödynnetty määrällisen tutkimuksen ja verkostoanalyysin menetelmiä. Työn keskeisimmät tulokset ovat tunnistetut asiakassegmentit ja heidän tarpeidensa pohjalta muodostetut palvelupaketit. Tulokset indikoivat asiakkaiden tarpeita ja tuloksia on analysoitu myös tuottajan näkökulmasta. Empiiristen tulosten lisäksi teoriaviitekehystä on kehitetty eteenpäin, jotta palvelukeskeiset teoriat voidaan ymmärtää yritysten näkökulman lisäksi asiakkaan näkökulmasta.

Mobile clinics in public health care: Integrated service offerings for rural elderly

This research is an analysis of the value and content of local service offerings that enable longer periods of living at home for elderly people. Mobile health care and new distribution services have provided an interesting solution in this context. The research aim to shed light on the research question, ‘How do we bundle services based on different customer needs?’ A research process consisting of three main phases was applied for this purpose. During this process, elderly customers were segmented, the importance of services was rated and service offerings were defined. Value creation and service offering provides theoretical framework for the research. The target group is South Karelia’s 60 to 90-year old individuals and the data has been acquired via a postal questionnaire. Research has been conducted as exploratory research utilizing the methods of quantitative and social network analysis. The main results of the report are identified customer segments and service packages that fits to the segments’ needs. The results indicate the needs of customers and the results are additionally analysed from the producer’s point of view. In addition to the empirical results, the used theory framework has been developed further in order for the service-related theories to be seen from the customer’s point of view and not just from the producer’s point of view.