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Background Very few evidence-based eHealth interventions for caregivers of people with dementia are implemented into practice. Municipalities are one promising context in which to implement these interventions due to their available policy and innovation incentives regarding (dementia) caregiving and prevention. In this study, two evidence-based eHealth interventions for caregivers of people with dementia (Partner in Balance and Myinlife) were implemented in 8 municipalities in the Euregion Meuse-Rhine. Partner in Balance is a blended care, 8-week, self-management intervention intervention designed to aid caregivers of people with dementia in adapting to their new roles that is delivered through coaches in participating health care organizations who are trained to use it to offer online support to their clients. Myinlife is an eHealth/mHealth intervention integrated into the Dutch Alzheimer’s Association website and available from the App Store or Google Play, designed to help caregivers of people with dementia use their social network to better organize care and share positive (caregiving) experiences. Objective This study’s objectives were to evaluate the success of the implementation of Myinlife and Partner in Balance and investigate determinants of their successful implementation in the municipality context. Methods This study collected eHealth use data, Partner in Balance coach evaluation questionnaires, and information on implementation determinants. This was done by conducting interviews with the municipality officials based on the measurement instrument for determinants of implementation (MIDI). These data from multiple sources and perspectives were integrated and analyzed to form a total picture of the determinants (barriers and facilitators to implementation in the municipality context). Results The municipality implementation of Partner in Balance and Myinlife showed varying levels of success. In the end, 3 municipalities planned to continue the implementation of Partner in Balance, while none planned to continue the implementation of Myinlife. The 2 Partner in Balance municipalities that did not consider the implementation to be successful viewed the implementation as an external project. For Myinlife, it was clear that more face-to-face contact was needed to engage the implementing municipality and target groups. Successful implementations were linked to implementer self-efficacy and sense of ownership, which seemed to be absent in unsuccessful implementations. Conclusions The experiences of implementing these interventions suggested that this implementation context was feasible regarding the required budget and infrastructure. The need to foster sense of ownership and self-efficacy in implementers will be integrated into future implementation protocols as part of standard implementation materials for municipalities and organizations implementing Myinlife and Partner in Balance.

Objectives The objectives were to (1) systematically review the literature on the implementation of eHealth interventions for informal caregivers of people with dementia, and (2) identify determinants of successful implementation. Methods Online databases were searched for articles about eHealth interventions for informal caregivers of people with dementia, providing information on their implementation. Articles were independently screened and inductively analyzed using qualitative analysis. The analysis was mapped onto the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Findings 46 articles containing 204 statements on implementation were included. The statements on implementation were grouped into four categories: Determinants associated with the eHealth application, informal caregiver, implementing organization, or wider context. Mapping of the determinants on the CFIR revealed that studies have focused mostly on characteristics of the intervention and informal caregiver. Limited attention has been paid to organizational determinants and the wider context. Conclusions Despite prolific effectiveness and efficacy research on eHealth interventions for caregivers of people with dementia, there is a critical dearth of implementation research. Furthermore, there is a mismatch between eHealth intervention research and implementation frameworks, especially concerning organizational factors and wider context. This review underscores the importance of future implementation research in bridging the gap between research and practice., Highlights • There is a lack of implementation research for these interventions. • Research focuses on the caregiver and the characteristics of the intervention. • Research should focus more on the implementing organization and wider context. • There is a mismatch between research and implementation frameworks. • More research is needed to develop appropriate theories to frame these studies.

Samenvatting Van der Weegen S, Verwey R, Spreeuwenberg M, Tange H, Van der Weijden T, De Witte L. Technologie om de fysieke activiteit te verhogen. Huisarts Wet 2016;59(6):248-52.

Background Given the increasing use of digital interventions in health care, understanding how best to implement them is crucial. However, evidence on how to implement new academically developed interventions in complex health care environments is lacking. This case study offers an example of how to develop a theory-based implementation plan for Partner in Balance, an electronic health (eHealth) intervention to support the caregivers of people with dementia. Objective The specific objectives of this study were to (1) formulate evidence-based implementation strategies, (2) develop a sustainable business model, and (3) integrate these elements into an implementation plan. Methods This case study concerns Partner in Balance, a blended care intervention to support the caregivers of people with dementia, which is effective in improving caregiver self-efficacy, quality of life, and experienced control. The large-scale implementation of Partner in Balance took place in local dementia case-management services, local care homes, dementia support groups, and municipalities. Experiences from real-life pilots (n=22) and qualitative interviews with national stakeholders (n=14) were used to establish an implementation plan consisting of implementation strategies and a business model. Results The main finding was the need for a business model to facilitate decision-making from potential client organizations, who need reliable pricing information before they can commit to training coaches and implementing the intervention. Additionally, knowledge of the organizational context and a wider health care system are essential to ensure that the intervention meets the needs of its target users. Based on these findings, the research team formulated implementation strategies targeted at the engagement of organizations and staff, dissemination of the intervention, and facilitation of long-term project management in the future. Conclusions This study offers a theory-based example of implementing an evidence-based eHealth intervention in dementia health care. The findings help fill the knowledge gap on the eHealth implementation context for evidence-based eHealth interventions after the trial phase, and they can be used to inform individuals working to develop and sustainably implement eHealth.

Sir,In a recent article, Heerkens et al. reconsidered the ICF scheme in an attempt to address critiques that in the current scheme the medical perspective is too dominant [1]. Based on literature r...

Background The system informs the nurse about levels of physical activity in the daily living of patients who are using the It’s LiFe! tool. The tool consists of an accelerometer that transfers data to a smartphone, which is subsequently connected to a server. Nurses can monitor patients’ physical activity via a secured website. Physical activity levels are measured in minutes per day compared with pre-set activity goals, which are set in dialogue with the patient.Objective To examine user requirements and to evaluate the usability of the secured website, in order to increase the probability of effective use by nurses.Method The needs and preferences of nurses towards the system were determined through qualitative research. The usability of the system was evaluated in a laboratory situation and during a three-month pilot study.Results A monitoring and feedback system to support patients in their intention to be more active was developed in a systematic way. Automatically generated feedback messages were defined based on the requirements of nurses. The results from the usability tests gave insights into how to improve the structure and quality of the information provided. Nurses were positive about the features and ease of use of the system, but made critical remarks about the time that its use entails.Conclusion The system supports nurses when performing physical activity counselling in a structured and profound way. The opportunity to support self-management of patients in between regular consultations needs further investigation, and adaptation into the clinical workflow of the nurses.

Background: Chronic obstructive pulmonary disease (COPD) is underdiagnosed in general practice. Our aim was to implement a population-based approach for the early detection of COPD and to assess its impact on primary care workload and costs, and the influence of socioeconomic status (SES). Methods: An observational study with mixed methods was performed in 10 Dutch general practices of either low or moderate to high SES. The Respiratory Health Screening Questionnaire was posted during a three-month period to all persons aged 45, 55, and 65 years (one age group per month). The practices calculated the risk, and patients at high risk of COPD were invited for spirometry at the practice. The general practitioner used the spirometric results and a consultation to establish a clinical diagnosis. Qualitative and quantitative data on workload, cost, and barriers were evaluated. Results: Ten practices returned 293 (35.3%) COPD risk tests for the three age groups. Participants from low SES practices responded better than those from moderate to high SES practices (40.8% vs. 30.5%). In practices with low SES 17.9% of the tests indicated high risk compared with 16.1% in practices with moderate to high SES. Nine patients (23%) were newly diagnosed with COPD. The healthcare providers' extra workload averaged 18.5 hours during the three months for one standard practice. The average cost of this survey programme (three age groups in three months) was (sic)520 for low SES practices and (sic)398 for moderate to high SES practices. All healthcare providers affirmed that the extra workload in this survey model is acceptable and feasible when finances are compensated. Conclusions: Early detection of COPD is feasible in daily life primary care. In moderate to high SES practices the costs of detecting COPD were less than in low SES practices.

Rationale, aims and objectives The admission to a hospital for elective surgery, like arthroplasty, can be planned ahead. The elective nature of arthroplasty and the increasing stimulus of the public to critically select a hospital raise the issue of how patients actually take such decisions. The aim of this paper is to describe the decision-making process of selecting a hospital as experienced by people who underwent elective joint arthroplasty and to understand what factors influenced the decision-making process. Methods Qualitative descriptive study with 18 participants who had a hip or knee replacement within the last 5 years. Data were gathered from eight individual interviews and four focus group interviews and analysed by content analysis. Results Three categories that influenced the selection of a hospital were revealed: information sources, criteria in decision making and decision-making styles within the GP– patient relationship. Various contextual aspects influenced the decision-making process. Most participants gave higher priority to the selection of a medical specialist than to the selection of a hospital. Conclusion Selecting a hospital for arthroplasty is extremely complex. The decision-making process is a highly individualized process because patients have to consider and assimilate a diversity of aspects, which are relevant to their specific situation. Our findings support the model of shared decision making, which indicates that general practitioners should be attuned to the distinct needs of each patient at various moments during the decision making, taking into account personal, medical and contextual factors.

Doel: Empirisch inzicht verkrijgen in de rol van gebruikersparticipatie bij het ontwerp van een website met CQI-keuzeinformatie. Dit is informatie over patientenervaringen in zorginstellingen. Methode: Op basis van literatuurstudie en eenexpert panel werd een papieren ontwerp voor een CQI-website voor electieve heup- en knieoperaties gemaakt. Dit ontwerp werd aangepast op basis van een kwalitatief-descriptieve studie onder 18 consumenten die recentelijk (

This study investigated the effect of playing Nintendo(®) "Wii Fit™ Plus" (Nintendo of America, Inc., Redmond, WA) on body balance and physical activity of nursing home residents.In a nonrandomized controlled trial within a nursing home, two intervention groups (both n=8) were exposed to the same treatment and compared with a control group (n=13). Intervention Group 1 consisted of elderly individuals with regular Nintendo "Wii Fit" experience for at least 1 year. Elderly persons who were novices to the Nintendo "Wii Fit (Plus)" participated in intervention Group 2. Control participants had no experience with the Nintendo "Wii Fit (Plus)" and did not participate in the Nintendo "Wii Fit Plus" sessions. Outcome measurements were taken at baseline and after the intervention, using the Berg Balance Scale and the LASA Physical Activity Questionnaire. Participants of both intervention groups played the Nintendo "Wii Fit Plus" for 10 minutes twice a week during 12 weeks.Although balance improved for all three groups, there was no effect of playing "Wii Fit Plus" (P=0.89). On physical activity, the intervention did have a positive effect (P=0.005); physical activity levels increased with a median of 54.3 (interquartile range, 63.1) minutes/day for intervention Group 1 and a median of 60.7 (interquartile range, 56.8) minutes/day for intervention Group 2.This study showed an effect of Nintendo "Wii Fit Plus" gaming on physical activity of nursing home residents, but not on their balance. The effect of physical activity should be consolidated in a randomized controlled trial in a broader population.

We reviewed the English and Dutch literature on evaluations of patient care information sys- tems that require data entry by health care professionals published from 1991 to 2001. Our objectives were to identify attributes that were used to assess the success of such systems and to test the ability of a framework developed by Delone and McLean for management information systems 1 to categorize these attributes correctly. The framework includes six dimensions or success factors: system quality, information quality, usage, user satis- faction, individual impact, and organizational impact. Thirty-three papers were selected for complete review. Types of study design included descriptive, correlational, comparative, and case studies. A variety of relevant attributes could be assigned to the six dimensions in the Delone and McLean framework, but some attributes, predominantly in cases of failure, did not fit any of the categories. They related to contingent factors, such as organizational culture. Our review points out the need for more thorough evaluations of patient care information systems that look at a wide range of factors that can affect the relative success or failure of these systems.

Summary Objectives: To compare two clinical workstations in one hospital with respect to technical, organizational, cultural and human factors. One clinical workstation was a GUI to the HIS. The other was an electronic patient record for stroke. Methods: Data were collected by means of in-depth interviews with end-users of both clinical workstations. The interviews were audio taped and transcribed for analysis. Results: End users assessed both clinical workstations as user friendly. Coordination between health care workers was perceived to be enhanced. However, in both situations poor communication between management, implementers and users resulted in uncertainty and skepticism about future perspectives. Furthermore, it appeared that inpatient and outpatient settings needed clinical workstations with different requirements for an optimal fit between work practices and information system. Conclusions: Regardless of the domain and content of a workstation, it can support coordination between disciplines. The communication concerning the information technology strategy deserves much attention. Finally, the requirements for inpatient and outpatient workstations differ.

Summary Objectives: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. Methods: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. Results: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. Conclusions: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

Background: A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results.Objectives: The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction.Methods: Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention.Results: The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (PConclusions: The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider.

This article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much detailed segments will delay the consultation of medical narratives. Validation of the results in daily practice is recommended.

Objective: Using electronic rather than paper-based record systems improves clinicians' information retrieval from patient narratives. However, few studies address how data should be organized for this purpose. Information retrieval from clinical narratives containing free text involves two steps: searching for a labeled segment and reading its content. The authors hypothesized that physicians can retrieve information better when clinical narratives are divided into many small, labeled segments (''high granularity''). Design: The study tested the ability of 24 internists and 12 residents at a teaching hospital to retrieve information from an electronic medical record — in terms of speed and completeness — when using different granularities of clinical narratives. Participants solved, without time pressure, predefined problems concerning three voluminous, inpatient case records. To mitigate confounding factors, participants were randomly allocated to a sequence that was balanced by patient case and learning effect. Results: Compared with retrieval from undivided notes, information retrieval from problem- partitioned notes was 22 percent faster (statistically significant), whereas retrieval from notes divided into organ systems was only 11 percent faster (not statistically significant). Subdividing segments beyond organ systems was 13 percent slower (statistically significant) than not subdividing. Granularity of medical narratives affected the speed but not the completeness of information retrieval. Conclusion: Dividing voluminous free-text clinical narratives into labeled segments makes patient-related information retrieval easier. However, too much subdivision slows retrieval. Study results suggest that a coarser granularity is required for optimal information retrieval than for structured data entry. Validation of these conclusions in real-life clinical practice is recommended. n J Am Med Inform Assoc. 1998;5:571 - 582. The primary function of the medical record is to sup- ply information for direct clinical practice. The med- ical record originally served as a memory-aid for the individual practitioner but has evolved to become a communication tool used by different professionals

The system informs the nurse about levels of physical activity in the daily living of patients who are using the It's LiFe! tool. The tool consists of an accelerometer that transfers data to a smartphone, which is subsequently connected to a server. Nurses can monitor patients' physical activity via a secured website. Physical activity levels are measured in minutes per day compared with pre-set activity goals, which are set in dialogue with the patient.To examine user requirements and to evaluate the usability of the secured website, in order to increase the probability of effective use by nurses.The needs and preferences of nurses towards the system were determined through qualitative research. The usability of the system was evaluated in a laboratory situation and during a three-month pilot study.A monitoring and feedback system to support patients in their intention to be more active was developed in a systematic way. Automatically generated feedback messages were defined based on the requirements of nurses. The results from the usability tests gave insights into how to improve the structure and quality of the information provided. Nurses were positive about the features and ease of use of the system, but made critical remarks about the time that its use entails.The system supports nurses when performing physical activity counselling in a structured and profound way. The opportunity to support self-management of patients in between regular consultations needs further investigation, and adaptation into the clinical workflow of the nurses.

The admission to a hospital for elective surgery, like arthroplasty, can be planned ahead. The elective nature of arthroplasty and the increasing stimulus of the public to critically select a hospital raise the issue of how patients actually take such decisions. The aim of this paper is to describe the decision-making process of selecting a hospital as experienced by people who underwent elective joint arthroplasty and to understand what factors influenced the decision-making process.Qualitative descriptive study with 18 participants who had a hip or knee replacement within the last 5 years. Data were gathered from eight individual interviews and four focus group interviews and analysed by content analysis.Three categories that influenced the selection of a hospital were revealed: information sources, criteria in decision making and decision-making styles within the GP- patient relationship. Various contextual aspects influenced the decision-making process. Most participants gave higher priority to the selection of a medical specialist than to the selection of a hospital.Selecting a hospital for arthroplasty is extremely complex. The decision-making process is a highly individualized process because patients have to consider and assimilate a diversity of aspects, which are relevant to their specific situation. Our findings support the model of shared decision making, which indicates that general practitioners should be attuned to the distinct needs of each patient at various moments during the decision making, taking into account personal, medical and contextual factors.

Summary Background: Guidelines are among us for over 30 years. Initially they were used as algorithmic protocols by nurses and other ancillary personnel. Many physicians regarded the use of guidelines as cookbook medicine. However, quality and patient safety issues have changed the attitude towards guidelines. Implementing formalized guidelines in a decision support system with an interface to an electronic patient record (EPR) makes the application of guidelines more personal and therefore acceptable at the moment of care. Objective: To obtain, via a literature review, an insight into factors that influence the design and implementation of guidelines. Methods: An extensive search of the scientific literature in PubMed was carried out with a focus on guideline characteristics, guideline development and implementation, and guideline dissemination. Results: We present studies that enable us to explain the characteristics of high-quality guidelines, and new advanced methods for guideline formalization, computerization, and implementation. We show how the guidelines affect processes of care and the patient outcome. We discuss the reasons of low guideline adherence as presented in the literature and comment upon them. Conclusions: Developing high-quality guidelines requires a skilled team of people and sufficient budget. The guidelines should give personalized advice. Computer-interpretable guidelines (CIGs) that have access to the patient’s EPR are able to give personal advice. Because of the costs, sharing of CIGs is a critical requirement for guideline development, dissemination, and implementation. Until now this is hardly possible, because of the many models in use. However, some solutions have been proposed. For instance, a standardized terminology should be imposed so that the terms in guidelines can be matched with terms in an EPR. Also, a dissemination model for easy updating of guidelines should be established. The recommendations should be based on evidence instead of on consensus. To test the quality of the guideline, appraisal instruments should be used to assess the guideline as a whole, as well as checking the quality of the recommendations individually. Only in this way optimal guideline advice can be given on an individual basis at a reasonable cost.

Decision Support Systems (DSS) are typically integrated in Electronic Health Record systems (EHR). By removing this integration full reuse of a DSS system is possible. The connection between the EHR and the DSS system should be standards-based and generic. We intend to demonstrate the viability of this setup by implementing it using PropeRWeb as EHR system, Gaston as DSS system, HL7v3 messages and the SOAP protocol.

The PropeR project studies a genric combination of an electronic health record (EHR) and decision support software (DSS). This study comprises different medical domains.Develop a distributed EHR system that is flexible enough to be used in different domains without major modifications.Use of standards and standardized specification and available open source components to develop an EHR system that meets the goals.PropeRWeb is a generic webbased EHR system that is flexible enough to easily accommodate different domains.Discussion of some of the problems encountered in the development of the EHR system.

The combination of a computer-based patient record system with a decision support system may give physicians the decisive push they need to accept such systems. In the PropeR-project we determine the requirements for a generic interface between both such systems and measure its potential impact on patient care. In this overview we describe the objectives, the experimental approach, and the current state of the PropeR-project. We also discuss the original positions behind the project.

The PropeR EHR is a multidisciplinary EHR system that is built using existing open source components. This paper discusses the implementation of this system and the advantages and challenges encountered when using open source components.

This article describes the architecture of an EPR system developed for the PropeR project. This EPR system not only aims at supporting home care of stroke patients, but is also designed in such a way that it can be ported to other medical services without much effort. We will briefly describe the Stroke Service and the related PropeR project. Starting from a list of requirements to construct a generic EPR system we will outline the architecture and describe the standards and methods used. Subsequently we describe the implementation and the problems encountered. In the discussion, we will go into the advantages and disadvantages of the tools and techniques we have used.

This paper reports on the role users played in the design and development of an electronic patient record. Two key users participated in the project team. All future users received questionnaires and a selection of them was interviewed. Before starting the development of the EPR, the attitude of users towards electronic record keeping, their satisfaction with the paper clinical records, their knowledge of computers, and their needs and expectations of computer applications in health care were measured by means of a questionnaire. The results of the questionnaire were supplemented with in-depth interviews. Users had a neutral attitude towards electronic record keeping. They were more positive about data entry of the paper records than data retrieval. During the development phase, but prior to the implementation of the EPR, a second questionnaire measured satisfaction with the paper records. Satisfaction appeared to be related to self-rated computer experience. Inexperienced computer users tended to be more positive about the paper records. In general, respondents did not have many expectations about electronic record keeping. A second series of interviews zoomed in on the expectations users had. Except for more concise reporting no beneficial effects of electronic record keeping were expected.

In this article, we describe the state of the art and directions of current development and research with respect to the inclusion of medical narratives in electronic medical-record systems. We used information about 20 electronic medical-record systems as presented in the literature. We divided these systems into `classical' systems that matured before 1990 and are now used in a broad range of medical domains, and `experimental' systems, more recently developed and, in general, more innovative. In the literature, three major challenges were addressed: facilitation of direct data entry, achieving unambiguous understandability of data, and improvement of data presentation. Promising approaches to tackle the first and second challenge are the use of dynamic data-entry forms that anticipate sensible input, and free-text data entry followed by natural-language interpretation. Both these approaches require a highly expressive medical terminology. How to facilitate the access to medical narratives has not been studied much. We found facilitating examples of presenting this information as fluent prose, of optimising the screen design with fixed position cues, and of imposing medical narratives with a structure of indexable paragraphs that can be used in flowsheets. We conclude that further study is needed to develop an optimal searching structure for medical narratives.

Item does not contain fulltext Universiteit Maastricht, 10 april 1997 Promotores : Hasman, A., Vries Robbé, P.F. de Co-promotor : Schouten, H.C.

Changes In the health care systems of the Western industrialized countries have placed new demands on the organization and delivery of nursing services. The trends towards shorter hospital stays, increased use of ambulatory services, and expansion of critical care services, have led to increased levels of patient acuity and a redefinition of hospital-based and community-based health care delivery. This in turn has necessitated a rethinking of the use of human resources and a reconfiguration of employment patterns. However, many countries have also been faced with a drastic restructuring of health care financing systems, and concomitant mandates for efficiency of resource utilization and effectiveness of service delivery within a context of renewed commitment to quality care. Within the human resources sector, many countries and health care systems are confronted with selective shortages of personnel, in particular nursing personnel. These changes have impacted on both the scope and functions of nursing managers. There is an increased expectation for efficient decision-making, planning, implementation, and evaluation (Sullivan & Decker, 1988). The use of information technology as an instrument to decision-making and management is emphasized (Ozbolt, Abraham, & Schultz, in press). While today’s nursing managers have responded well to these new responsibilities and expectations, they are also confronted with their relative lack of formal preparation.