PAPERLESS HEALTH RECORDS: THE WAY FORWARD FOR EFFECTIVE HEALTHCARE DELIVERY SYSTEM: IN UNIVERSITY OF UYO TEACHING HOSPITAL – UYO
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Study Level: BTech, BSc, BEng, BA, HND, ND or NCE
This study focuses on the Paperless Health Records: the way forward for effective healthcare delivery, in University of Uyo Teaching Hospital, Uyo. The study adopted descriptive survey which was carried out with the use of questionnaire in which the opinion of doctors, nurses, health information managers, administrative officer, account staff, pharmacist, radiographers, medical laboratory scientist, finance and supply staff, community health staff, microbiologists, hematologists and dietetic staff were sought. Stratified sampling technique was used in selecting thirteen department and simple random sampling was used in selecting 200 respondents from thirteen department. The specific objectives were to examine requirement in instituting Paperless System of Patient Health Information, to assess the key features of paperless base record keeping, to find out factors militating against computerization of patient health information, to deal exhaustively with the specific objectives of the course of the study and problem raised in the study, some literature were reviewed. The data for the study was generated from a well- designed questionnaire, copies which were administered to 60 male and 140 female respondent selected for the study. 200 questionnaire were retrieved for the analysis representing 100% to facilitate a precise result of the investigation. Three hypothesis were formulated and tested using chi-square technique. The result of the test showed that, there was need for instituting Paperless System of Patient Health Information in University of Uyo Teaching Hospital Uyo. The study further revealed that certain factors militate against computerization of patient Health Information in University of Uyo Teaching Hospital Uyo. From the study, it could be concluded that Paperless Health Record help in the systemized collection of patient and population electronically stored health information in a digital format. Among others it was recommended that the management of the hospital should organized a seminar to create awareness of Paperless Health Record System to all health workers, constant power supply should be provided for smooth implementation of the Paperless Health System and also training of staff in terms of operating the system.
TABLE OF CONTENTS
Certification – – – – – – – – – i
Dedication – – – – – – – – – ii
Acknowledgments – – – – – – – – iii
Abstract – – – – – – – – – iv
Table of Contents – – – – – – – – v
List of Table – – – – – – – – – vi
List of Abbreviation – – – – – – – – vii
1.1 Background to the Study – – – – – – 1
1.2 Statement of the Problem – – – – – – 1
1.3 Objective of the Study – – – – – – 2
1.4 Research Questions – – – – – – – 2
1.5 Hypothesis – – – – – – – – 3
1.6 Scope of Study – – – – – – – 3
1.7 Significance of the Study – – – – – – 3
1.8 Operational Definition of terms – – – – – 4
REVIEW OF RELATED LITERATURE
2.1 Introduction – – – – – – – – 6
2.2 Electronic Healthcare Record System – – – – 6
2.3 Electronic Health Records – – – – – – 9
2.4 Benefit of Electronic Health Records – – – – 12
2.5 Technology Acceptance Model (TAM) – – – – 15
2.6 Ease of Use and Information Technology Support – – – 17
2.7 Comparison with Paper-Base Records – – – – 17
2.8 Improved Accuracy – – – – – – – 19
2.9 Reduced Cost – – – – – – – – 19
2.10 E- Prescribing – – – – – – – – 19
2.11 Technical Features – – – – – – – 20
2.12 Philosophical View of the Electronic Health Record – – 20
2.13 Change Management and the nature of Change – – – 21
2.14 Summary – – – – – – – – 23
3.1 Introduction – – – – – – – – 24
3.2 Research Design – – – – – – – 24
3.3 Description of Research Population – – – – – 24
3.4 Sample and Sampling Technique – – – – – 24
3.5 Data Collection Instruments – – – – – – 25
3.6 Reliability and Validity of Instruments – – – – 25
3.7 Data Collection Procedure – – – – – – 25
3.8 Method of Data Analysis – – – – – – 26
RESULTS AND DISCUSSION
4.1 Introduction – – – – – – – – 27
4.2 Demographic Information of Respondents – – – – 27
4.3 Analysis of Findings – – – – – – – 30
4.4 Hypothesis – – – – – – – – 32
4.5 Discussion of Findings – – – – – – 37
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction – – – – – – – – 39
5.2 Summary – – – – – – – – 39
5.3 Conclusion – – – – – – – – 40
5.4 Recommendations – – – – – – – 40
References – – – – – – – – 42
Appendices – – – – – – – – 43
1.1 Background to the Study
In line with Global practice, the demand for paperless system of health information has increased responding to the digital re-evaluation. Healthcare records include wide range of data in a comprehensive or summary form including demographics, medical history, allergies, laboratories test result, radiology images, vital signs, personal state. There are many benefit of using paperless health record for both patients and hospitals, reducing the cost, improving the quality of health services, ease of access for a large number of authorized people, information storing and ensuring confidentiality when required Petra Knaup et al., (2007).
Paperless health records system provides the possibility of record linkage for input at different time has brought tremendous improvement into healthcare delivery system in terms of records creation, storage, maintenance, preservation and processing of information and with the maintenance of patient’s accurate database, efficient and effective healthcare delivery is enhanced.
Affiah, (2004), Stressed that electronic health record (EHR) is the use of computer to obtain, arranged file and eradication of the paper system (manual system) of patient health information and the use of the paperless system health information.
Paperless health records system gives room for easy research and prevents the researcher from carrying many folders about. This reduces the burden of opening one folder after the other and sometimes not being conversant with doctors handwriting. It also makes statistical compilation easy because records of eases are viewed at a glance. Paperless health record also enhances accurate diseases surveillance and epidemiological report because of the online presentation of ceases.
1.2 Statement of the Problem
The problem of patient coming to hospital to stay for a long time without being able to see a doctor happens as a result of using manual health information system (paper-based health records) which the health record personnel may or always find it difficult to retrieve for urgent medical attention.
In University of Uyo Teaching Hospital, all out-patient records are kept in their different consultative clinics, the patient find it difficult to transfer his or her case folder from one consultative clinics to the other for medical care. This always prolong the waiting time of patient through the delay in retrieving patient health records. There is increase in work load for health information personnel’s because they have to walk to different clinics in the hospital to search for a patient case folder.
These manually kept record or information are subject to tear and wear through continuous usage which may eventually lead to the following:
Poor follow-up of persons with chronic condition
Missing case notes/ folders for review
Inadequate information for health care team
Unauthorized and accessibility of patient’s case note for continuous care by health care team
Unauthorized access and usage of patient’s healthcare record for personal studies.
1.3 Objectives of the Study
The main objective of this project work is to examine the “importance of paperless health record” while the specific objectives are as follows to;
- Examine requirements for instituting paperless system of patient health information.
- Assess the key features of paperless base record keeping.
- Find out the factors militating against computerization of patient health information.
1.4 Research Questions
The research questions are:
- What are requirements in institutionalizing paperless system of patient health information?
- What are the key features of paperless records keeping?
- What are the factors militating against computerization of patient health information?
The following hypothesis will be tested to accomplish the objective of this study.
- Ho: That there are no requirements in institutionalizing paperless system of patient health information.
- Ho: That there are no key features of paperless records keeping.
iii. Ho: That there are no factors militating against computerization of patient health information.
1.6 Scope of the Study
This research was based on a sample of staff in Health Information Department – University of Uyo Teaching Hospital.
This study was conducted in the University of Uyo Teaching Hospital, Uyo, a tertiary health institution in Akwa Ibom State.
This research concentrated on “Paperless Health Records: the way forward for effective healthcare delivery system”. University of Uyo Teaching Hospital is situated along Uyo – Abak Road at Ediene Ikot Obio Imo, bounded by Ikot Ntuen Nsit to the North, Ediene Ikot Obio Imo to the South, Ikot Oku Ikono to the East and use Ikot Ebio in Uyo Local Government Area to the West.
The researcher was restrained on the course of the study distribution and collection of the questionnaires to different staff, typing of questionnaires, photocopying of related materials. Non-availability of current information in textbook also constituted a limiting factor to the researcher.
1.7 Significance of the Study
The importance of the research lies in the following reasons:
To Patient – With the successful implementation of paperless health records it will reduce patient waiting time.
To Health Information Managers – This research may reveal useful recommendation for the health information department of University of Uyo Teaching Hospital to adopt the application of paperless health record. It will also bring about positive approach toward proper management of patient health information and reduction in missing case notes of patients.
To Doctors/ Nurses – It will increase the rate of communication between different healthcare facilities concerning patient care.
To Hospital Management – At the end of this study, it is expected that this research will go a long way in helping the management of University of Uyo Teaching Hospital – Uyo to see the need of Introducing Electronic Health Records.
To Government – Its will be considered by the federal government to be transformational and integral to healthcare reform. It will help government to see the need of Paperless Health Record Adoption.
To Researchers – Successful use of paperless health record, it will help researchers to streamline the research data collection process, manage the data itself and be used to warehouse, analyze and report on the data in near real time.
To Public – With adoption of paperless health record will result in better customer stratification through fewer lost charts, faster refills and improve delivery of patient educational material.
To Student – It will help to student to use Paperless Health Record to learn and communicate in a clinical setting.
1.8 Definitions of Operational Terms
Paperless System – It is the system aimed at using electronic devices in documentation of health or relevant information for retrieval when required.
Health – It is a state of complete physical, mental and social wellbeing of an individual not merely the absence of disease or infirmity.
Automation: Is the act or process of converting the controlling of a machine or devices to a more automatic system such as computer or electronic control.
Paper- Based Records – Is a record system where data or information are collected, collated, preserved and retrieved in a physical form through manual method that is without the use of an electronic device or computer.
Health Information Systems – It is a system that integrate data, collection processing, reporting and use of information necessary for improving health services effectiveness end efficiency through better management at all levels of health services.
Electronic Health Records – Electronic Health Records (EHR), Electronic patient records are evolving concept which are defined as the systematic collection of electronic health information about individual patients or population Gunter and Terry (2005).
Technological Acceptance Model (TAM) – It is an information system theory that demonstrates how users accept and use certain technology. The model suggests that when users are provided with a new technology, a number of factors influence their decision about how and when they will use it.