1.
Entezarjou, Artin
(författare)
eVisits in the digital era of Swedish primary care
2022
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,and subsequent care utilization in the digital era of primary care in Sweden.Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studiesevaluating the eVisit platform Flow in various clinical contexts.- Paper I was a comparative study of digital triage decisions when presented with automated patienthistory reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in apanel of five physicians was compared to triage decisions by a machine learning model trained usingdata labelled by an expert primary care physician.- Paper II was a qualitative focus group study of nurse and physician experiences of digitalcommunication at three primary health care centers using the platform. Themes were generated usingqualitative content analysis as described by Graneheim and Lundman.- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adultpatients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit controlgroup was recruited retrospectively using letters. Paper III primarily compared antibiotic prescriptionrates per sore throat visit, while paper IV primarily compared subsequent physical health careutilization within two weeks for patients in the Skåne Region.Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learningmodel. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium ofcommunication highlighting challenges in interpreting symptoms through text as well as alterations in practiceworkflow using asynchronous communication. Antibiotics prescription rate within three days was not higher aftereVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). Nosignificant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization ofphysical health care when assessing common infectious symptoms. Given staff experiencing uncertainties ininterpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of manymodalities to access primary care, with focus placed on facilitating patient-centered professional judgement bystaff, rather than automation of complex decisions.
2.
Petersson, Jesper, 1974
(författare)
Geographies of eHealth: Studies of Healthcare at a Distance
2014
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This thesis examines the proliferation of healthcare services using information and communication technology to overcome spatial and temporal obstacles. These services are given such names as telemedicine and telecare, which are sometimes grouped together as telehealthcare under the umbrella term eHealth. My main argument is that a prevalent and overoptimistic rhetoric of how the possibilities of digitalization are expected to produce a homogenous and ubiquitous healthcare space conceals many of the spatiotemporal complexities involved in introducing telehealthcare and in the overall organizing of healthcare. To counteract such simplifications, I contend that we need a relational understanding of the technical and the geographical as always nested in the social and vice versa. With such an approach, it is arguably possible to begin to tease apart the many spatiotemporal entanglements of these innovations and to trace their political ramifications. This position is developed by integrating perspectives from science and technology studies with insights from human geography. The four constituent papers of this thesis pursue this argument in qualitatively grounded case studies of telehealthcare and its geographies. Paper I looks at various initiatives for fetal tele-ultrasonography, demonstrating that this practice cannot be reduced to a mere transparent relay for the speedy transmission of digital information across space and time. The paper investigates how its introduction could affect medical knowledge production, power hierarchies, and subject positions, for example, the status attributed to the fetal figure. Paper II traces Swedish transformations of telehealthcare. The use of telemedicine to reach those outside medicine’s range has arguably been accompanied by efforts to achieve intra-organizational streamlining via telemedicine. This process has continued with the emergence of telecare for personal use directed toward the overlapping groups of the elderly people and patients with chronic conditions. I contend that this shift can be understood through a geographical lens as attempts to save space and time by keeping as many patients as possible out of costly hospitalization and preventing them from engaging scarce specialist resources. Paper III compares four telemedicine projects in Sweden. In detailing how the purpose of practicing telemedicine differed between these projects in relation to, for example, the specifics of distance, care availability, and treated medical conditions, the paper demonstrates the existence of many versions of telemedicine. Whereas this fluidity could further the spread of telemedicine, it could also cause problems. To various actors wanting to use telemedicine in a homogenous and fixed way for national streamlining purposes, this diversity has generated confusion when they wished to align telemedicine in a preferred direction. The paper concludes that technology travels best when it can contain both fluid and fixed relationships. Paper IV argues that, whatever is claimed about creating a space- and time-independent healthcare by means of telehealthcare, the use of telecare to connect the standardized spaces of healthcare with the fluid everyday lives of elderly people and patients with chronic conditions actually works by unfolding new spaces of visibilities and establishing new temporalities as well. By investigating these spatiotemporalities, I demonstrate how these applications draw together discourses on individual freedom with medically derived algorithms and concerns about how to make best use of scarce healthcare resources.
3.
Andersson, Réka
(författare)
Gränsdragningar i Vårdens Vardag : Hanteringen av arbetsrelaterad psykisk ohälsa i det svenska välfärdssystemet
2017
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Psykisk ohälsa i arbetslivet är ett stort och växande problem i välfärdssamhället. Problemet har flera bottnar och väcker många frågor om vem som har ansvar, vad det egentligen är för ett slags fenomen och hur det bör hanteras. Den här studien undersöker hur arbetsrelaterad psykisk ohälsa hanteras av yrkesverksamma inom vården, med fokus på företagshälsovård och primärvård. Intresse riktas mot hur yrkesverksamma personerna resonerar kring arbetsrelaterad psykisk ohälsa, vilka dilemman de ställs inför och de strategier de har för att hantera dessa. Den söker också svar på ansvarsfrågan kring detta komplexa problem, inte minst i ljuset av privatiseringen av företagshälsovården.I studien används ett tvärvetenskapligt perspektiv, där begrepp från teknik- och vetenskapsstudier (STS), professionssociologi och organisationsteori kombineras för att analysera olika aspekter av vårdens hantering av arbetsrelaterad psykisk ohälsa. Det empiriska materialet bygger i huvudsak på intervjuer med läkare, psykoterapeuter, kuratorer, arbetsterapeuter, psykologer, rehabiliteringskoordinatorer och beteendevetare, men inkluderar även observationer inom primärvård och företagshälsovård. Hanteringen av arbetsrelaterad psykisk ohälsa i vårdens vardag präglas av att orsaksbilden till problemet är komplext, ansvarsfördelningen otydlig och att psykosociala orsaker till sjukdom är kontroversiellt. I studien diskuteras utmaningarna och möjligheterna kring hanteringen av detta komplexa problem i bred bemärkelse. I analyserna uppmärksammas de yrkesverksammas gränsdragningar kring både ansvar och fenomenet arbetsrelaterad psykisk ohälsa. Begreppet kunskapsinfrastruktur används för att förklara och förstå den kunskapsmässiga och materiella struktur som de yrkesverksamma verkar inom. Analyserna visar att de yrkesverksamma har ett pragmatiskt förhållningssätt och använder olika strategier för att skapa sig handlingsutrymme i hur de hanterar arbetsrelaterad psykisk ohälsa.
4.
Henriksen, Eva, 1952-
(författare)
Understanding in Healthcare Organisations- a prerequisite for development
2002
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This study proposes that poor understanding of the structures, processes and outcomes of organisations seriously hampers collaboration between professional groups in care organisations. Three care settings were investigated: follow-up of patients with heart disease, an intensive care unit and care services for older people. The overall aim was to investigate how people understand structures, processes and outcomes in care organisations. The participants were patients, patient representatives, healthcare professionals, managers and politicians. A qualitative approach was used. Thematic analysis and grounded theory were employed in analysing the data. Despite considerable efforts, no major changes took place over a 7-year period as to how cardiac follow-up services were understood. The system of cardiac follow-up services was found fragmented in its organisation and in the way individuals understood it. The results indicate that care professionals, patients and leaders have dissimilar understandings. The data suggest that care is organised from a professional-centred perspective rather than from a holistic worldview of the patients’ total context. Leaders in intensive care perceive their organisation as a learning organisation. However, in daily work healthcare tends to function to what can be described as a mass production approach to care. This state of conflict caused confusion and chaos among the leaders. The municipal elderly care services and the county council’s geriatric organisation had difficulties in co-ordination. Older people were perceived as passive recipients of healthcare, rather than as consumers whose well being and outcome were a reflection to the quality of the service. The study concludes that despite the major changes that have taken place in the Swedish health and elderly care organisations over the past years, healthcare professionals’ understanding of their work has gone largely unchanged. Their understanding of care structures and processes did not change despite outside pressures. Lack of understanding of what others understand hampers development with the result that care organisations risk stagnation.
5.
Talantsev, Anton, 1983-
(författare)
Handling severe uncertainty in strategic project appraisal : Methods and applications of context analysis
2020
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
The long-term success or failure of a strategic project is largely shaped by its context. Therefore, the assessment of the external factors influencing the fulfilment of project long-term goals is vital for the effective project appraisal and planning.However, many projects are embedded in a complex, dynamic, and multi-stakeholder environment creating a condition of severe uncertainty. These aspects make both the assessment of a project context and the prediction of the outcomes challenging. In the face of these challenges, the overall aim of this thesis is to propose both conceptual thinking and practical approaches for the project context analysis.To this end, the presented work has adopted a design science research and formal approaches from the fields of systems analysis, risk assessment and decision sciences, to systematically understand the problems of the context analysis, and to develop and evaluate the solutions. This thesis presents novel methods for assessing project context, which have been implemented in the following decision support tools:• a tool for strategic fit assessment,• a tool for context factor analysis,• a tool for corporate reputation risk assessment,• a toolkit for stakeholder-based impact assessment of a policy,• a toolkit for assessing intervention strategies in pandemics.The proposed methods have been applied and evaluated in case-studies within various domains, such as business strategy, development aid, energy policy, and public healthcare. These studies have demonstrated the adequacy and usefulness of the proposed methods for supporting decision making in situations with varying levels of uncertainty. This indicates the potential of the methods to improve the effectiveness of the project appraisal practice.This research has concluded that a project context is a multi-faceted concept, and, thus, no single method is capable of the comprehensive assessment. Instead, an assembly of specialised but complementary approaches is required to adequately model and assess both the various aspects of the context and the uncertainties of different types.
6.
Lutz, Peter A.
(författare)
Tinkering Care Moves : Senior Home Care in Practice
2016
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This dissertation builds on the current anthropological studies of care relations in practice. It draws inspiration from science and technology studies (STS) and postfeminist technoscience. A qualitative ethnographic approach grounds the empirical data collection and analysis. This entails ethnographic fieldwork with senior home care in the United States and Sweden during 2007–2008 and 2011–2012. Analytical attention centers on how movements situate various tensions of senior home care in practice. Four interrelated published works comprise the main thematic chapters. Each article exemplifies how human and nonhuman relations move and mediate care. They develop several heuristic terms that advance ideas about how older people, aging bodies, technologies, spaces, and times that tinker each other through movements of care in practice. The comprehensive summary frames these articles with an overview of the primary thematic orientations and methodological concerns. A discussion of the main contributions and implications of the dissertation concludes the work.
7.
Gund, Anna, 1980
(författare)
On the Design and Evaluation of an eHealth System for Management of Patients in Out-of-Hospital Care
2011
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This thesis covers the design and evaluation of a generic web-based eHealth system into real clinical settings. Moreover, the use of an off-the-shelf video communication system for out-of-hospital care is tested and evaluated. A large part of the thesis will cover the design process of the web-based system (WBS) for out-of- hospital long term disease management. The systems were implemented in two very different settings: heart failure care and neonatal home healthcare.The methods of evaluation are questionnaires, including both patients and nurses. Also, data extracted from a blood pressure monitor, and data extracted from the prototype system database are used in the evaluation.The first study, performed in 2008, indicated that the prototype developed was applicable in the patient group (heart failure). However, several issues concerning the system were found, resulting in the development of a new prototype system. The two subsequent studies, heart failure care and neonatal home healthcare, were performed using the new system. Results from these two studies indicate that the WBS is usable for two very different applications.In heart failure care compliance with the system is very good, however in neonatal care the results are ambiguous. The neonatal evaluations show that even though the patients may be positive towards eHealth systems, the necessity of care personnel participation is vital. If there is no feedback, the patients lose interest and find the system useless.A questionnaire survey studying attitudes towards information and communication technology (ICT) as a tool in health care, and also studying the attitudes towards home follow up, was also performed. The target group was healthcare personnel in heart care, and the questionnaire was sent out to 84 cardiology and medicine clinics in Sweden. All 21 counties and regions in Sweden were included in the dispatch, and of these responses were collected from 17. The results indicate a large interest and confidence in healthcare ICT, and well as in home follow-up and monitoring of patients. A comparison between nurses and physicians indicate a slight difference where nurses in general are more positive than physicians.
8.
Eriksson, Erik, 1977
(författare)
A Service Management Perspective on Healthcare Improvement: Integrating Social Context
2016
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
The current dissertation argues that ideas from service research should be given a more prominent position in improving healthcare that is capable of managing current and future challenges. The integration and combination of intangible resources, such as knowledge and skills, constitute the service in this thesis; thus, service is conceived as a verb. A central notion in such conceptualization is value co-creation, implying that healthcare providers may only offer potential value, which is realized as real value by people in their broader lifeworlds. Consequently, the healthcare provider is often only one of many actors in the individual’s value-creation process – in which resources from a multiplicity of actors are integrated and combined. One challenge that is particularly addressed in this thesis is unsatisfying inhabitant/patient perceptions concerning how healthcare is executed. More specifically, this refers to interpersonal aspects, including interaction between inhabitant/patient and provider, access to adequate information, and prerequisites to actively participate in one’s own care. Another challenge addressed herein is disparities between groups in society. A mainstream service management perspective is deemed relevant in targeting the first challenge, with foci on the inhabitant’s/patient’s active role rather than the internal affairs of the organization; interaction rather than results; and providing a holistic view rather than treating healthcare in isolation. In order to face the second challenge of disparities between groups, I argue that it is necessary to explicitly integrate the social context, which is claimed to have been neglected in traditional service research. Such context includes not only a diversity of actors, but also societal structures that influence – and are influenced by – the healthcare meeting and thus the individual’s prerequisites to actively participate in her or his care. By adopting a moderate social constructionist position – which contrasts to the individualism characterized by mainstream service research – the focus of the thesis moves from singular to plural, from individual to groups in society. On one hand, in such a position, categorization of individuals into groups is not uncomplicated. On the other hand, healthcare improvements are enabled on a collective level. The constructionist position also permeates conceptions of knowledge: rather than an absolute “truth,” knowledge is about different perspectives. An extension of this reasoning is that healthcare needs to manage multiple perspectives to achieve improvement. Consequently, the purpose of this thesis is not to proclaim a service management perspective as a universal solution, but rather to enhance its position among a diversity of mutually complementing perspectives. The empirical material draws from three studies, discussed in five papers. The first study sought to increase knowledge of three groups’ perceptions on parenthood in a child health service context. The second study mainly addressed the reasons why men and women reported complaints in healthcare. The third study addressed how healthcare providers and community representatives could contribute to increased participation in a screening program in an area with a large number of foreign-born inhabitants. Cumulatively, the studies illuminate the potential of a service management perspective to improve healthcare, not least being the focus on the inhabitant’s/patient’s perceptions, but also their active role and the inclusion of actors in the individual’s broader lifeworld such as family members and the local community. In line with a service management perspective, the interactional aspects are argued to be important enablers for individuals to participate in healthcare. However, by integrating the social context, it is also revealed that interaction may also constitute a constrainer of possibilities for individuals or groups to be participative. A service perspective integrating social context also offers possibilities, not least by enriching the emerging field of improvement science. Through lifeworld-situated perceptions, in which groups’ perceptions beyond healthcare are identified, healthcare may be improved to better address group members’ needs given their broader life situations. Representative co-creation implies that a collective’s unique knowledge and skills are used productively in order to improve healthcare that manages diversified needs and expectations.
9.
Snyder, Hannah
(författare)
Health Care Customer Creativity
2016
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Crafting and stimulating service innovation is considered a main research priority and remains a challenge for service providers. One suggested component of stimulating service innovation is customer creativity. Customers who adapt, modify and transform services or products to better suit themselves are increasingly being recognized as a source of competitive value and innovation. It has been proposed that understanding and supporting the customer’s value creating practices is the key to creating and sustaining value over time in health care. Health services directly address a customer’s well-being and have a significant impact on his or her quality of life. In these types of services, the service outcome is highly dependent on the activities of the individual customer. Health care services often require customers to participate extensively, over long periods of time, with limited support and control. Health services also stretch far beyond the particular service setting into the customer’s daily life. While research, policy, and legislation have all emphasized the active role of health care customers, such customers have traditionally had few opportunities to design their health care services. Nevertheless, health care customers solve health-related problems and engage in self-care and medical decision-making on a day-to-day basis, although this creativity is often unknown to the service provider.To understand how health care customers can enable service innovation, this thesis seeks to conceptualize and investigate the concept of customer creativity in health care. The thesis focuses on customer creativity, not only as an outcome, but also as a dynamic and contextualized process that can be enhanced. The thesis combines insights from health care research with service and innovation research to provide build a framework for health care customer creativity. Building on five papers, the research develops an understanding for health care customer creativity. The individual papers are based on systematic literature reviews as well as empirical data in the form of customers’ ideas for service innovation collected through diaries.The results of the thesis suggest that despite the negative nature of the service, health care customers are creative. Given the opportunity, health care customers can provide creative ideas and solutions on a multitude of aspects, both within and outside the health care setting. This provides the potential to view the health care experience through the customers’ eyes and take part in their creativity in spheres where the service providers have not traditionally had any access. This thesis contributes to the literature by providing a framework for health care customer creativity that recognizes the concept as a complex interplay of factors operating at the individual, contextual, and situational levels. The proposed framework specifies the health care specific factors upon which customer creativity depends, with the intention of positing potential research directions and developing an enriched theory of health care customer creativity.
10.
Liu, Yuanhua, 1971
(författare)
Usability Evaluation of Medical Technology: Investigating the Effect of User Background and Users' Expertise
2009
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Medical devices play a major role in diagnosis and therapeutics in the healthcare systems. The basic features of medical devices concern safety and efficient clinical performance. Nowadays, usability evaluation is an important part of the design process of medical devices. The aims of this thesis work were to investigate the effect of user profiles on usability evaluation results and to provide practical advice on choice of users as test subjects when conducting usability evaluations of medical devices. Five studies, with analytical and empirical evaluation approaches with different foci, were included in the work. In the studies, consideration was given to user background and users’ expertise as well as to user interfaces of different levels of complexity. The user background aspect was taken as the focus for the analytical evaluation approach, while users’ expertise was taken as the focus for the empirical evaluation approach. Cognitive Walkthrough was employed as an example of an analytical evaluation method to investigate user background, while usability tests were used as an example of empirical evaluation method to investigate users’ expertise. The results showed that medical device user background settings can influence the outcome of an analytical evaluation results, i.e. when more ergonomic factors were included in the user background settings, a wider range of usability problems were detected. User expertise is an important factor for the results of empirical usability tests. Users’ familiarity with tasks can be used as an important criterion for classification of user expertise. The quantitative analysis of the empirical evaluations implies that the effect of users’ expertise may be invisible when interacting with a simple user interface, but visible when interacting with a more complex user interface. Expert users outperformed novice users when interacting with a complex interface but not when interacting with a simple interface.The qualitative analysis of verbal explanations and statements, causes of errors and redesign proposals stressed the differences between novice and expert users in terms of decision-making, presentation and judgment, which implied that expert users’ use experience and novice users’ interaction experience differ in contributing to product design and development. Insufficient domain and interaction knowledge were consistently identified as typical causes of errors for novice users. The differences of information organization between previously experienced user interfaces and the interfaces interacted in the usability tests affected expert users’ task completion. Expert users made task-related errors due to terminology issues and interaction-related errors due to their ‘old’ mental model of how to interact with the user interface. Based on the results, different strategies are suggested to be used when choosing test subjects for usability evaluations in different interaction situations. A guideline and some practical advices were proposed as well to medical industrial companies about how to conduct usability evaluations on medical devices.
