CHALLENGES IN ELECTRONICS RECORDS MANAGEMENT AMONG MEDICAL RECORDS OFFICERS IN UPTH

TABLE OF CONTENT

Title page

Approval page

Dedication

Acknowledgment

Abstract

Table of content

CHAPTER ONE

1.0   INTRODUCTION 

1.1        Background of the study

1.2        Statement of problem

1.3        Research questions

1.4        Objective of the study

1.5        Significance of the study

1.6        Scope of the study

1.7       Definition of terms

CHAPETR TWO

LITERATURE REVIEW

2.1 introduction

2.2 conceptual review

2.3 empirical review

CHAPETR THREE

3.0        Research methodology

3.1    sources of data collection

3.3        Population of the study

3.4        Sampling and sampling distribution

3.5        Validation of research instrument

3.6        Method of data analysis

CHAPTER FOUR

DATA PRESENTATION AND ANALYSIS AND INTERPRETATION

4.1 Introductions

4.2 Data analysis

CHAPTER FIVE

5.1 Introduction

5.2 Summary

5.3 Conclusion

5.4 Recommendation

Appendix

Abstract

The importance of quality patience health information medical record to healthcare facility cannot be overemphasized. However, when professional and effective management of this record is hampered, it impacts negatively on the generality of patience care. The advancement of technology has changed the way the entire of healthcare industry functions. An electronic medical record is one of the advancement of technology that is significantly and gives a great benefit in medical field. The development of electronic medical record can help to increase the productivity and profit of medical institutions. Most countries in developed countries are increasingly using an electronic medical record (EMR) to improve work process, patient safety and quality of healthcare.                                                            CHAPTER ONE

                                        INTRODUCTION

1.1 Background of the study

The awareness of health care quality has been growing for many years and this has been significant issue to the Ministry of Health (MOH) Malaysia. One characteristic that needs to be considered in improving quality of health care is records management. With the shift in technology, implementation of electronic medical records (EMR) is arising and thus, evolving the health care environment. The phrase EMR itself has underwent changes which set out from “computer stored medical records” subsequently computerized patient record (CPR), computerized medical record (CMR), computer-based patient record system (CBPR), electronic health record (EHR),and automated medical record (AMR) (Fisher,1999). Under The Seventh Malaysian Plan (Government of Malaysia, 1996) EMR system implementations started out in the year 1999. The use of information technology (IT) implemented in EMR is now widely accepted in hospitals as well as clinics. This technology based improvement, is seen to make better exchange of information and bring out more effective communication among doctors. Implementation of EMR is also seen as a promising IT based solution in health care quality improvement (Gastaldi et al, 2012). This is due to the competency of EMR system to handle large amount of information and data within the health system and hence capable of supporting the diverse needs of clinical, organizational and management of health care (Reina et al, 2012). Health Information Management (HIM), also known as Medical Records Management, is the scientific practice of acquiring, analyzing and protecting and preserving both digital and traditional health information/ medical records which are vital to providing quality and timely health care services. Health is wealth and one of the statutory institutions that provides and supports citizenry’s health is hospital. Hospitals, according to Yeo (1999) are those institutions that deal with life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Good medical care also relies on good record keeping. Without accurate, comprehensive up-to-date and accessible patient case notes, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have serious consequences. The researcher is of the view that associated records, such as X-rays, specimens, drug records and patient registers, must also be well cared for if the patient is to be protected. Good records care also ensures the hospital’s administration runs smoothly: unneeded records are transferred or destroyed regularly; keeping storage areas clear and accessible; and key records can be found quickly, saving time and resources. Records also provide evidence of the hospital’s accountability for its actions and they form a key source of data for medical research, statistical reports and health information systems (Yeo, 1999). Records management according to NHO Healthcare Records Management Steering Committee (2007) “is the systematic and consistent control of all records in which they are held throughout their lifecycle. Where: Systematic Records need to be managed in a planned and methodical way; Consistent approach Records of the same kind should be managed in the same way. Whether electronic or paper, the management of the record must be consistent; Consistency over time Managing records is always vital whether resources are adequate or scarce; Control Organizations. need to control how records are produced, received, organised, registered, stored and retrieved, retained, destroyed or permanently preserved and All Records that includes all documents, active and inactive, formal ones and informal regardless of the medium in which they are held.is the systematic and consistent control of all records throughout their lifecycle”. Therefore, the art of preservation and management of health records is an issue that has generated series on concern overtime. This is so because of its role in supporting medical care as well as a platform for monitoring the health history of patients. Many writers have argued that such effort is a basis for referral service and improved medical care delivery. It is therefore necessary to probe into some constrains that forestall the availability of health records in hospitals and suggest some necessary steps to the hospital managers on how to enhance its improvement. Unfortunately, many low-income countries, however, have struggled to initiate large-scale electronic medical record systems. While some low-income countries have been able to attract technical and financial resources to install patient information systems at some sites, these require significant investments for their successful implementation. In fact, these systems require abundant resources including skilled labour, technological, and financial means, all of which can be difficult to procure in low-income settings (World Health Organization, 2012). The EMR system integrates clinical data, patients’ records, decision support application programmes and transaction processes within a hospital. With these integration, the system has a potential big impact on the hospital performance (Gastaldi et al, 2012). From a doctor’s point of view, EMR allows a better way to collect, store, retrieve and analyze medical information. The analyzed information can then be used to seek the best treatment for a patient and in turn provide a quality care for the patient (Richards, et al 2012). With schematic connections and interdisciplinary understanding, EMR implementation will be able to provide effective and efficient patient, physician and clinic management as well as enhancing good outcome.

1.2 STATEMENT OF THE PROBLEM

In most African countries like Nigeria, preservation and conservation of hospital documents and records has posed a serious problem. The deterioration of materials forms the basic problem of registries and gives rise to preservation and conservation of records. Therefore, knowledge of the causes of deterioration of materials and how to cater for these materials is essential for all librarians and others who are concerned about the preservation and conservation of information stored in books and non-book formats. Hence, it is in this premise that this study is set to examine some challenges that affect the preservation and conservation of records electronically in university of Port Harcourt teaching hospital

1.3 OBJECTIVE OF THE STUDY

The study has one main objective which is divided into general and specific objective, the general objective is to ascertain the challenges in electronic record management among medical record officers in UPTH. The specific objectives are:

1. i) To examine the effect of electronic record management system on doctors efficiency
2. ii) To ascertain if there is any relationship between electronic record management system and patient effective health management in UPTH

iii) To examine the challenges encountered by medical record officers in UPTH in managing patience record electronically

1. iv) To proffer suggested solutions to the identified problem

1.4 RESEARCH QUESTIONS

The following research questions were formulated by the researcher to aid the completion of the study;

1. i) Is there any effect of electronic record management system on doctors efficiency?
2. ii) Is there any relationship between electronic record management system and patient effective health management in UPTH?

iii) Are there challenges encountered by medical record officers in UPTH in managing patience record electronically?

1.5 RESEARCH HYPOTHESES

The following research hypotheses were formulated by the researcher to aid the completion of the study;

H₀: there is no relationship between electronic record management system and patient effective health management in UPTH

H₁: there is a relationship between electronic record management system and patient effective health management in UPTH

H₀: there are no challenges encountered by medical record officers in UPTH in managing patience record electronically

H₀: there are challenges encountered by medical record officers in UPTH in managing patience record electronically

1.6 SIGNIFICANCE OF THE STUDY

It is believed that at the completion of the study, the findings will be of great importance to the record management officers of university of Port Harcourt teaching hospital as the study seek to explore the benefits and the challenges of electronic record management system on effective patience medication. The study will also be of importance to researcher who intend to embark on a study in a similar topic as the findings of this study will serve as a reference point to further studies. Finally, the findings will be of great importance to students, teachers, academia’s, and the general public as the findings will add to the pool of existing literature and also contribute to knowledge in the study area.

1.7 SCOPE AND LIMITATION OF THE STUDY

The scope of the study covers the challenges in electronic record management among medical record officers in University of Port Harcourt teaching hospital UPTH, but in the course of the study, there are some factors that limit the scope of the study;

AVAILABILITY OF RESEARCH MATERIAL: The research material available to the researcher is insufficient, thereby limiting the study

TIME: The time frame allocated to the study does not enhance wider coverage as the researcher have to combine other academic activities and examinations with the study.

FINANCE: The finance available for the research work does not allow for wider coverage as resources are very limited as the researcher has other academic bills to cover.

 1.8 OPERATIONAL DEFINITION OF TERMS

Record

Records are created/received by an organization in routine transaction of its business or in pursuance of its legal obligations.

Electronic record management

Electronic records management [ERM] is using automated techniques to manage records regardless of format. Electronic records management is the broadest term that refers to electronically managing records on varied formats, be they electronic, paper, microform, etc

Medical record

A medical record is simply a record of a patient’s health and medical history. Depending on the level or need of care a patient has, records may vary, but all medical records will contain some common information

1.9 ORGANIZATION OF THE STUDY

This research work is organized in five chapters, for easy understanding, as follows

Chapter one is concern with the introduction, which consist of the (overview, of the study), statement of problem, objectives of the study, research question, significance or the study, research methodology, definition of terms and historical background of the study. Chapter two highlight the theoretical framework on which the study its based, thus the review of related literature. Chapter three deals on the research design and methodology adopted in the study. Chapter four concentrate on the data collection and analysis and presentation of finding.  Chapter five gives summary, conclusion, and recommendations made of the study.

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