UNIVERSITY OF EASTERN FINLAND Faculty of Social Sciences and Business Studies Department of Business
HEALTH RECORD MANAGEMENT IN HOSPITALS OF NEPAL
Master’s Thesis, Health and Business Umesh Timilsina (285320)
2018/2019
- 1 - ABSTRACT
UNIVERSITY OF EASTERN FINLAND Faculty of Social Sciences and Business Studies Master’s Program in Health and Business
TIMILSINA, UMESH: Health Record Management in Hospitals of Nepal Master’s Thesis: Pages (74) and appendix (10 pages)
Supervisor: Päivi Eriksson September 2019
Key concepts: Health Records, Medical Records Management, Electronic Health Records, Hospital, Patient.
The aim of this study was to understand existing practices of health record management in hospitals of Nepal. To understand the existing practices in this field, the general experience and outlook of the health workers, information management staffs and health managers’ was gathered. Qualitative method was used to gather the needed information. The study was carried out in public, private and community hospitals of Nepal to collect the relevant information. Semi structured in-depth interviews were done with nine participants (hospital directors or data managers and health workers) in each hospital. The result of the interview was analyzed and record management practices and challenges associated in keeping health records was identified.
The findings were identified using nine different themes with seventeen sub categories during this study. The study shows that both paper- based and electronic health record management practices were found in the hospitals of Nepal. The record management practice is mostly paper based whereas partial digitalized record system was found. Moreover, private hospitals were found to be more flexible in terms of adoption and development in digitalized health records but government and community hospital were found to be lacking in proper move forward in technological development.
The research mostly highlighted institution-wise variation in health record management practices.
Some similarities in private and public hospitals were found but the differences in record management practice were also noticeable. The clear understanding of record management
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practice in hospitals was difficult because there was no clear and defined rules regarding health record management in these hospitals. No clear system was defined to make the practice of record management and the position of health record officer was not identified or filled. Lack of trained manpower as well as limited numbers of people designated for health record management was identified.
Ethical issues of patient health record management and record disclosure were not clear. The hospital budget assigned for health record management was very low. No system had been established for record analysis, publication based on health record management. The study also documented lack of proper policies, guidelines, funding, monitoring and supervision to strengthen health record management in Nepal.
Introduction of proper policy in health record management seems to be the necessity in hospitals of Nepal. Furthermore, investment in identification of problems related to record management as well as system development was recognized to improve the service delivery and quality of care to strengthen the health record management in hospitals of Nepal.
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ACKNOWLEDGEMENTS
I would like to express my sincere thanks to Päivi Eriksson for her invaluable supervision and useful guidance and encouragement throughout my journey of thesis writing. Also I am indebted
to her for providing me with valuable directions when at times I was routed to a different path rather than being able to derive a clear picture of my thesis objectives and helping me throughout
the process.
I would like to thank all respondents (the hospital members) who cooperated kindly and responded to all my questions without any hesitation during the data collection process. I must
appreciate their kind help and generosity during the preparation of this thesis.
Also I would like to thank my friends who helped me to arrange meetings with the hospital staffs and provided me assistance in finding the right contact and information.
Umesh Timilsina
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TABLE OF CONTENTS
ABSTRACT - 1 -
ACKNOWLEDGEMENTS - 3 -
TABLE OF CONTENTS - 4 -
1. INTRODUCTION - 7 -
1.1 Topic of the Research - 9 -
1.2 Purpose of the Study - 10 -
1.4 Structure of the thesis - 12 -
2. THEORECTICAL BACKGROUND - 13 -
2.1 History of Health Record Management - 13 -
2.2 Health Record Systems Overview - 14 -
2.2.1 Paper Based Health Record System - 14 -
2.2.2 Electronic Health Record System (EHR) - 15 -
2.3 Health Record Management - 16 -
2.4 Health Record Management Systems in Nepal - 18 -
2.5 Theoretical Framework used in the study - 19 -
3. RESEARCH METHODS - 21 -
3.1 Methodological Approaches - 21 -
3.2 Data Collection - 22 -
3.3 Data Analysis - 24 -
4 RESULTS - 26 -
4.1 Research Findings - 26 -
4.2 Summary of the Results - 54 -
5. DISCUSSION AND CONCLUSION - 61 -
5.1 Results and Discussion - 61 -
5.2 Conclusion - 67 -
5.3 Future Research Needs based on the findings - 68 -
REFERENCES - 70 -
APPENDIX - 74 -
APPENDIX 1: RESEARCH QUESTIONNAIRE - 74 -
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LIST OF ABBREVIATIONS
ACS American College of Surgeons
AHIMA American Health Information Management Association ARLNA Association of Record Librarians of North America ART Anti-Retroviral Therapy
AHW Auxiliary Health Worker
BPKIHS BP Koirala Institute of Health Sciences
CBIMNCI Community Based Integrated Management of Neonatal and Childhood Illness DPHO District Public Health Office
DOTS Directly Observed Treatment Short course EHR Electronic Health Records
ER Emergency Room
GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit HIV Human immunodeficiency virus
HMIS Health Management and Information System HPCSA Health Professions Council of South Africa HRD Health Record Department
HW Health Worker
ICD International Classification of Diseases ICU Intensive Care Unit
ID Identity Document/ Identification IDI In-Depth Interview
IPD In-Patient Department MPI Master patient index MRN Master Register Number MRO Medical Record Officer
- 6 - NHRC Nepal Health Research Council NHS National Health Service
OPD Out Patient Department PLHIV People Living with HIV/AIDS WHO World Health Organization
- 7 - 1. INTRODUCTION
Nepal is one of the developing countries with very less development in the field of healthcare.
With the population of approximately 30 million (2016), the average life expectancy stands at 70.25 (2016). The total expenditure on health care is 137 dollars per capita and total expenditure on health is 5.8 percentage of GDP (2014) (WHO, 2016). Nepal has various problems associated with healthcare system and management. However this research is focused on the grassroots problems that exist in healthcare management of Nepal. As the reform has to be made from the root level, this study tries to give some overview in health record management practice in hospitals of Nepal.
Health record management is a practice of record management that is responsible for recording of patient’s health information, its maintenance, use and disposal. This can include patient’s history, clinical findings, diagnostic test results, patient’s progress and medication etc. Health record management is also referred as health information management (HIM). A proper management system can help increase the patient safety and reduces the risk of mistakes. Health records also termed as Medical records are one of the most important elements in health record management. Health record is new and recently used term and gives broader meaning to the context compared to the term medical record (Homan, 2007).
The definition of Medical or health record is explained by various organizations. Health Professions Council of South Africa (HPCSA) states health record as “any relevant record made by a health care practitioner at the time of, or subsequent to a consultation and/or examination or the application of health management”(HPCSA, 2008). WHO defines Medical records as a reference to gain knowledge in patient’s health history which facilitates in the proper treatment of the patient as well as continue care and also enable the medical researches and health statistics (WHO, 2006).
Health records are the written statement of patient’s health for the treatment in the present and for the continuing care (WHO, 2006). It includes all the detailed information on patient’s health progress, medication as well as clinical findings, pre and postoperative care and diagnostic test results. The properly written document helps doctors in correct treatment of the patient. The main objective of maintaining health records is to monitor the patient and to keep
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track of the progress. It is also important for medical research, medical or paramedical education, medical audit and statistical studies. Health record also serves a purpose in insurance cases, personal injury suits, criminal cases, and workers compensation cases. These documents basically provide the evidence in various medical cases (Bali et al., 2011).
Health records are a broad compilation of information conventionally placed in the health record but also covering aspects of patient's physical, mental, and social health that may not certainly relate directly to all the condition of the treatment (Medical Dictionary, 2012). So based on the definition we came to know that health records are not only things related to particular health problems, it is broad topic which include much more information related to patient physical, mental and social wellbeing.
The research on health record is rarely done in the context of Nepalese hospitals. The articles and researches on health records can be found here and there and in small pieces. Some articles regarding health record are found in local newspapers but mainly focused on new innovation rather than the existing one. During the research I realized that most of the research is done related to the importance of Electronic health record which is a method to keep all health related data of patient entered in computer, stored in drives and clouds and new innovation in healthcare whereas, there is lack of studies on how the health records are handled in current scenario. The researchers are focused in finding the alternative innovations in healthcare but the analysis to the current problem seem to be missing (Dhungel, 2017).
According to World Health Organization (WHO) International statistical, classification of disease (ICD-10) has been introduced in Health Management Information System (HMIS).
Some training courses on ICD-10 have been introduced for medical record officers in BP Koirala Institute of Health sciences (BPKIHS) in Dharan City. Most hospitals in Nepal are currently following ICD-10 coding system for inpatient discharge. Moreover, District and Zonal hospital have also started to send inpatient morbidity report of inpatient discharged using ICD-10 Coding among which 30 percentage of hospitals are public (WHO, 2007).
The importance of health record and its usefulness in healthcare has been widely discussed by various organizations like World Health organization (WHO), American Health Information Management Association (AHIMA), National Health Service (NHS) Foundation etc. These
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organizations have highlighted the basic components of medical reports, procedures for handling proper health record as well as stakeholders involved in the process.
Health records involve the documents that are created according to the outcome of patient care. According to the HPCSA (2008), these documents include:
1. A note taken in hand-written form by the health care professional.
2. Notes that are taken by previous health professionals or practitioners attending health care, which includes a typed patient’s discharge summary.
3. Recommendation or referral letters from or to the other health care professionals.
4. Laboratory reports or evidences such as histology sections, cytology slides and printouts from computerized analyzers like X-ray reports, ECG traces, etc.
5. The record of audio visuals such as photographs, videos and tape-recordings.
6. Forms of the Clinical research and clinical trial data.
7. Other forms that are completed during the health related interaction such as documentation on injury or illness, insurance forms, and disability assessments.
8. Death certificates and the reports of autopsy.
1.1 Topic of the Research
The topic of this research is “Health Record Management in Hospitals of Nepal”. This research topic explores the health record management practice in Nepalese hospitals. The research will be focused on three different types of hospitals i.e. Private, Public and Community hospitals.
The research topic is concentrated on identifying the current health record management practices in hospitals of Nepal. Also it tries to recognize the people associated with handling the health records and the problems associated in health record management practice. This research topic aims to give some light to the grass root problems in this area and help the future researcher to explore more on the issue.
- 10 - 1.2 Purpose of the Study
On the basis of the theoretical discussions, the purpose of this study is to gain deeper understanding on the topic of health records management. The idea is to study previous studies made on the topic and to compare the theory with the ongoing process of health record management in the hospitals of Nepal. The primary objective of this research is to comprehend the concept of health record management, its significance in healthcare delivery and the process involved health record management in the context of Nepalese hospitals.
Based on the purpose and aim of the study, the research question is presented as follows:
“How are health records managed in hospitals of Nepal?”
By answering the primary research question, I will be able to understand how the records are currently being managed in the hospitals of Nepal. This part of the research is expected to explain how management of the health records work in Nepalese hospitals i.e. how are health records organized and how are they processed as well as secured. This study illustrates the question: Who are the main responsible people involved in health record management.
Furthermore, primary research question of this research also explores how the health records are retrieved and used for future references especially for the research purposes.
In order to supplement the primary research question, I have set some secondary objectives to the thesis. These sub-questions are necessary to find the deficit in current health record management practices in hospitals of Nepal. This study would assist in future development of health record management as well as to understand the gap and differences on existing ongoing health record management process in Nepalese hospitals with the modern record keeping and innovation in health information management. Furthermore, the secondary objectives are expected to give understanding regarding the challenges associated with record management and the how the record keeper, managers or medical doctors deal with these challenges. The given research is intended to explore the documents of existing practices of health record management in Nepal.
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The primary and secondary objectives set the main purpose of the research. If I simplify the concept of the research, it can be explained with three 3Ps: Process, People and Problem. The questions are: what are the processes of managing health records in Nepalese hospitals? Who are the people involved in record keeping? And what problems are associated in the process?
Process carries the primary objective of the research whereas people and problem are the secondary objective of the study.
During my study I realized that it is important to understand the key challenges that are associated with health or medical record management of Nepal. The study of key challenges is expected to provide assistance to the future studies in development and innovation of health record management. Also, it would help medical doctors, managers and health record officers to contribute innovative ideas in health record management. The secondary research question provides researchers with the direction and guidelines for the future research in this field.
Medical or health records have been researched under various organizations like WHO in Health record manual: a guide for developing countries, American Health Information Management Association (AHIMA), and by various national organization in the health management organizations. The importance of health records, the documentation procedure and the process involved has been defined by these organizations, however in context of Nepal, the research seems to be lacking. And there are no specific guidelines to address health record management in Nepal.
Therefore, following research objectives were developed and the specific objectives mentioned below support to gather findings and guide overall research.
How do hospitals of Nepal manage health records in Nepal?
How do hospitals in Nepal explore and document various types of information management practices?
How do hospitals of Nepal deal with key challenges and development opportunities of health record management?
- 12 - 1.4 Structure of the thesis
Chapter 1 includes introduction on the subject, topic of the research, purpose of the study which consists research questions and the reasoning for the research questions and the structure of the thesis.
Chapter 2 includes the theoretical background of the study. In this chapter, I have reviewed related literatures and described theoretical understanding of health records, health record management and history of health record management. This section also includes the type of health record management and current health record management practice in Nepal. Moreover this chapter also provides the theoretical framework of the study which gives the clear outline of the objective of thesis. This theoretical section also integrates the previous similar studies done on the topic which further guides the research to discuss key challenges and development opportunity.
Chapter 3 highlights the methodology used in this study. This chapter discusses methodological approaches and explains the qualitative method, observation and in-depth interview. Furthermore, this section also includes the data collection method used in the research and how data are collected. This part of the thesis provides extensive analysis of the data which will help to explore more on results.
Chapter 4 includes the result of the empirical research and presents the summary of the results. It outlines my findings related to my research question. The summary is presented in comparative form between hospitals to provide the clear picture on similarities and differences that exist in different types of hospitals.
Chapter 5 presents the discussion of the research based on the results. Based on the discussion, this section provides the conclusion of the research. Further, it explains and interprets the result in wider context and focuses on whether the result was according to the expectation or not. Also, it discusses the challenges and possibility of future development in health record management in Nepal. Moreover, in this section I present the possibility of future research in health record management.
- 13 - 2. THEORECTICAL BACKGROUND
Chapter 2 highlights the theory on health record management. This chapter mainly focuses on the history of health record management, different types of health record management practices and also explains the current scenario of health record management system in hospitals of Nepal. Further, this chapter also provides the conceptual framework used in this research.
2.1 History of Health Record Management
Health record management has evolved as a result of various changes in the history of Health Information management. During the 1920s, the healthcare professional realized that the documentation of patient health records benefited to both healthcare providers and patients.
This recognition among healthcare provided was the first step to keep health information by the healthcare providers. The first health information management was recognized in 1928 by the Association of Record Librarians of North America (ARLNA) which was later named as American Health Information Management Association (AHIMA). ARLNA was formed after 10 years of hospital standardization (Gibson et al., 2015).
In 1918, American College of Surgeons (ACS) started the movement to establish the basic requirement standard for hospitals which succeeded in the formation of position for medical record clerk. Earlier health records were documented on papers and note and the responsibility of the record librarians/ clerk was defined to maintain the health record and file them in order. In 1932 the professionals of Health Information Management realized the need of training and education therefore adopted a formal curriculum in health information management (Sayles et al., 2013).
With the advancement of technology of the 60s and 70s brought a huge development in terms of transferring the paper based health records into electronic health records. With the development of computers, the patient information was recorded in computers. As necessity in record keeping increased over years, the healthcare industry started the EHR software development for keeping electronic health records in 1980s. During this period, software development in healthcare emerged magnificently. The database for patient information was introduced; Master patient index (MPI) was used and gained huge popularity among the
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healthcare organizations. During 1990s, with the introduction of various computer applications, the development in health record management was massive successful.
However, the technology was still lacking in inter-communication between departments in the health organizations. Also the medical errors and death of the patient was on the rise. During 2000s with the innovation of doable Electronic Health record system, the accuracy and medical errors started to decrease (Brooks, 2015).
2.2 Health Record Systems Overview 2.2.1 Paper Based Health Record System
The paper-based health record has been in use since long ago. The paper-based health record system involves processing, storing and accessing the patient information in paper format within the healthcare institution. Paper based health record comprises of unstructured or less structured free texts. Paper records are still the main source of information in daily care of patient for various reasons. It acts as a reminder to the health care providers to report illness.
Paper based reports are used as a tool to communicate between clinicians. Paper based evidences are given preferences in various countries. The German legal system still considers paper health record as primary evidence. Also, many health insurance companies use paper- based health records to evaluate the appropriate details on patient admission and length of stay at hospital (Stausberg et al., 2003).
According to Sellen and Harper, “an examination of why and how paper is used in existing work processes can be seen as a way of directing and inspiring the design of new technologies.” Paper records are considered as a passive way of supporting clinical activity which fails to deliver the main purpose in delivering the correct information to the correct providers in correct form in the right time (Harper, 1997).
The use of paper-based records has advantages such as they are simple, cost effective, widely accepted, mobile and can enter subjective data. Although there paper records have several limitations such as easily destroyed, required a sufficient space to storage, need to organize properly, access to the information may not be uniform, complex to manage and analyze, sometimes papers may be missed or misplaced, difficult to access remotely or from different locations (Sridhar GR et al, 2009). Paper based records may have bundle of pages or high in
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volumes that may also have storing problem. They may need to be stored in a special place in order to protect confidentiality, integrity, and security of health records (Ariffin et al., 2018).
The transformations of health record information from paper based to electronic based system have brought significant benefits to the clinical and operational practices. The transition from paper based to electronic health record required several aspects such as implementation planning, technologies, trainings, healthcare provider’s roles &responsibilities (Ariffin et al., 2018), and health management unit. A study suggested that, for the successful implementation of EMR, the management requires a clear understanding of the benefits, ensure choices and consider the whole practice workflow (Rouse, 2010).
2.2.2 Electronic Health Record System (EHR)
A study by Thielst (2007) suggests that effective use of technology at hospital can improve the clinical procedures, uniformity in practice, regulations, public standards and protocols to improve patient health outcomes and patient safety. Adoption of Electronic health record has mostly been initiated from developed countries. Electronic health records not only provide patient data but also help to achieve better health care (Scholl et al., 2011). It also reduce mistakes and helps in decision making as well as improve medical conditions (Watkinson- Powel, 2012). EMR is a computer-based system that stores, organizes, and retrieves patient detail information to improve the quality of care and ensure patient safety. Quality and efficiency in health care might be improved using electronic health records (Jha et al., 2006).
Overall an Electronic Health Record (EHR) is a digital tool to collect and retrieve the patient’s health record. A patients’ demographic information, medical history, examination procedures, medical & Lab reports and progress reports of health and illness can be obtained from Electronic Health Records. Therefore, application of EHR systems can reduce the health care costs; improve patient safety, health care efficiency and outcomes (EHR) (Ariffin et al., 2018; Devkota, 2013). It also documents and monitors the progress of patient, sign and symptoms, care plan, information and research that can be accessed from the hospitals under the protection of confidentiality, security and patient privacy.
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Recently, electronic medical record system has been introduced in District Trishuli Hospital Nuwakot in collaboration with GIZ Nepal to collect patient based data for improving health record management at hospital, quality of data and smooth functioning of hospital. The effectiveness of the project will determine the expansion of electronic health record in other hospitals and health facilities of Nepal (NHRC, 2018).
Some of the software developer companies e.g. Eastlink Pvt. Ltd. are providing hospital with management software (web-based hospital management information system) for government and private hospitals, Nursing Homes, Clinics and Pharmacy. Depending upon type of services provided by the hospital, this web-based hospital management information system has created several features for the patient records and hospital management. These included demographic information, medical history, pathology, lab tests, medical reports, treatments, human resource management, reporting system, security system, maintenance etc. (EastLink Technology, 2018).
2.3 Health Record Management
Good management is prerequisite for increasing the effectiveness and efficiency of health services (Lippeveld et al., 2000). The World Health Organization (WHO) has identified health information as a critical for achieving health for all. This also means that good management leads to improvement of health information systems. Information is essential at all stages of health services management, from the periphery to the center and also required for health system planning and management (Lippeveld et al., 2000). This implies utilization of health information for decision making are not only required by policymakers and directors but also needed by healthcare providers, general practitioners/ doctors and health workers. In some of the health institution, health information is collected by untrained health workers or without using technologies.
Data entry has continuously been a major problem to the adoption of electronic records by the health workers. Medical data entry includes relevant use of clinical terms, where structured data are coded. These coding and extracting of the health record require more work from the health professional (Walsh, 2004). In most of the hospital’s health professionals are responsible for taking health records. There is evidence that paper-based records are easier to
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keep record and read although it can be difficult to search information as it lacks structure (Walsh, 2004). Although the size and structure of records might vary as per the purpose of information collection, it can be said that paper-based information requires time and energy for processing the required health information.
Ideally, health record system involves keeping records at registration department and using handwritten notes during patients visit. The data is collected from the health record either paper based or electronic and later processed using Health Management Information System (HMIS) (Malunga & Simon, 2017). However different departments have their own responsibilities of taking appropriate records (Kay & Purves, 1996). Electronic health record system also involves same procedures of writing notes and then entering in electronic system by coding data (Walsh, 2004). Handwritten records possibly permit more thought for centering on how to diagnose and oversee the patient’s illness. Health workers are responsible in ensuring and managing the records of the patients.
According to Archer et al., (2011) electronic health records provides patient centered health records and easy to provide access to the patients for self-management of their health. Every individual has right to access their health records (Goss, 2004), although because of privacy and security reasons, the information is not allowed to other than patient in some of the health institutions. A study also shows that around 42% of the population in United States keeps health records for themselves and their families and most of these are in paper based forms (Taylor, 2004). Information access provided to the patients and family has significantly improved in self-management of health and wellness. Electronically recorded health information allows patient to access entire medical history in a single place. This information may be needed to both patient and healthcare providers’ in future follow-up meetings in same or different settings.
There is evidence that use of electronic health records in hospital settings not only reduces cost of treatment but also improves the quality of the treatment (Detmer et al., 2008). Patient with long-term health problems, disabilities and multiple health problems may experience direct and immediate benefits from using their health records. In some of the cases they do not need separate treatment cost for hospital visit again and in some of the cases some funding organization helps patient to treat with these disabilities and chronic diseases. The advantage
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of keeping health records also include easy access to up-to-date health information and results and also better communication with patient and healthcare providers (Tang et al., 2006).
The health records often include information on education background and lifestyle, (Tang et al., 2006) (e.g. education, economy, social status, family history, living or working environment, diet, exercise, smoking, weight loss and working habits). The practices of recording health information vary according to nature of the patients or identified diseases.
Some hospitals records basic information of patients whereas some hospitals do advanced recording system and collect information. Patients with illness keep some kind of summaries of their health records like patient visit card, diagnosis report, laboratory report, and treatment or medication card or bills and doctors name. However, some patients also keep appointment notes, diaries and questions to be asked during the visit.
2.4 Health Record Management Systems in Nepal
Nepal is a small developing country with significant progress in health care management over the years. Nepal has made some progress in health sector after the adaptation of national health policy in 1991. Various establishment of sub-health posts (SHPs), health Posts (HPs), primary health care centers (PHCs), district hospitals (DHs) and regional hospitals have been providing primary, secondary and tertiary care over the years. The progression in health management is significant over the years (WHO, 2007).
However, Healthcare in Nepal is still lacking in various aspects of innovation and technology.
Hospitals, who are directly linked to be the main source of health care providers, are still seeking for significant changes. Hospital management is a new trend in Nepal and is considered as a new discipline. Only in 2001, Pokhara University started the first hospital management courses in Nepal. Over the years few more private hospitals as well as colleges have started course in this field under health service management (NOC, 2011).
The study of health records is combined with the study of healthcare management or healthcare information management. Health record management is evolving around the world with digitalization and new innovations are overtaking the health system. However, in the context of Nepal, the management of health records is still in primitive age. The hospitals are
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still working under the paper based format and therefore the need of this research becomes vital.
Nepal health sector has initiated to digitalize since 1990s with the integration of parallel reporting structures for both the national Health Management Information System (HMIS) and the Logistics Management Information System (LMIS). Ministry of health and population manages both the system centrally (GIZ, 2018). The government of Nepal has been allocating the budget in the national level for various digital health initiatives. Some of the initiatives includes the digital health information management system DHIS2 (electronic or e-reporting), and the IMIS digital software platform for handling social health insurance of Nepal. Ministry of health and population has been planning to introduce a new position of hospital manager in all public hospitals which has a capacity of 50 or more beds, introducing how digital solutions can stimulate health system reforms. EHR systems initiative improvements in the efficiency and quality of care provided to the patients. They provide real-time data on almost any aspect of hospital care, be it the number and type of consultations, the fees billed by departments, or the drugs coming into and out of the pharmacy (GIZ, 2018).
2.5 Theoretical Framework used in the study
Based on the reviewed literature and study objectives, theoretical framework of the study was developed. The theoretical framework was primarily developed in order to study the existing practices of health record management in hospitals of Nepal. The conceptual diagram intends on identification of problems in health record management. For this, problems, people and process are recognized as key elements to the study.
The conceptual diagram also includes the policies, programming, implementation and monitoring as a secondary elements that affects the health record management process. The main objective of the research which is highlighted in the conceptual diagram is to contribute to the future development and innovation and eventually improve the health record management in Nepal.
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Figure 1: Conceptual Framework
Improved Health Record Management
in Hospitals Implementation
& Monitoring Policies
Future Development &
Innovations
How health records are managed in hospitals?
Problems Process
People
Programming
- 21 - 3. RESEARCH METHODS
Chapter 3 highlights the methodology used in this study and the study design. This chapter discusses the qualitative method, observation and in-depth interview. Furthermore, this section outlines the types and nature of data and analysis methods used in the study. In this section, I will explain how I conducted the research and the methodology used for data collection and analysis.
3.1 Methodological Approaches
The general objective of my research study was to understand existing practices of health record management in hospitals of Nepal. For my research, the most appropriate method was qualitative research method and in-depth interview was most suitable. Qualitative research is scientific approach of collecting data through observation and gathering experiences or understanding of the people. Qualitative research is also effective in finding the specific information about the values, opinion, behaviors and social contexts in particular settings in particular groups (Mack, 2005). To collect qualitative data on health records I followed the similar approach and identified peoples, process and problems associated with health record management practices in Nepal.
In-depth interview is a qualitative research method which includes conducting the interviews intensively with small group of people and gain their perspective on certain idea, situation or program. This method can be useful to gather the detailed information and explore their experiences and expectations (Boyce & Neale, 2006). In-depth interview was needed in my research because there are very less research done in this topic and it was necessary to conduct the interview in depth about how the respondents deal with health records, What would be their situation and what perspective would they have in this area.
The methods used in this research are expected to bring the most significant outcomes. In this study, I chose hospitals with three different setting for my case study. The case study of this research was necessary as it supports the why, how and what questions as a condition and is considered a good methodological approach in qualitative as well as quantitative method depending on the aim and objective of research question (Eriksson & Kovalainen, 2008). It was necessary for my research to choose different types of hospital in different location to get
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the overall picture of the health record management practice of Nepal. As Nepal provides health facilities through different setting like Private, Public and Community (Semi-Private), it was necessary to incorporate the contrasting cases. Also that these hospitals deliver health service differently and the administrative process also varies according to the nature of hospital. The chosen location is also important because Nepal is one of the developing countries and health facilities and management differs based on the location. By choosing the case with different setting and cases, I expect to gain deeper understanding on my objectives.
To document the situation, my study design included hospital managers, medical doctors, other health workforce or medical record section staffs who are responsible for patient level data collection. Various data collection setting and tools used will mention later below.
3.2 Data Collection
The research goal was to get the deeper understanding of health record management practice in Nepal. For this, I used semi-structured interviews as it helps the participant to express their views and opinions freely. The study was carried out in three hospitals of Nepal from April - May, 2019. In Nepal there are three types of hospital established so far i.e. government (Public) hospital, Private hospital and community hospital. Three Hospitals from three locations Kathmandu, Bhaktapur and Darchula with different background were chosen for understanding their practices of health record management.
The participants of the interview were contacted through mutual contact and they were provided with the basic background of the interview purpose and objectives beforehand. In all the hospitals the survey form was handed over to each respondent. This was necessary as it could save the precious time of the health professionals and also prepare them for the interview. Firstly, the consent form was sent to get the official confirmation of their participation and four forms with different questions were formed for respondents with different position or background. The participants were informed that they could ignore any questions if it puts them in difficult position as well as the anonymity of the participation was assured. The participants were also pre-informed that they could share any of their individual opinion and experience freely during the interview process.
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Pre-tested Semi Structured in-depth interview (IDI) guidelines were used and one to one interview with hospital directors or data managers and Health Workers was done. In every hospital three different staffs i.e. Hospital Director/Senior staff, Information Manager/
medical recorder and doctor/health worker involved in record keeping were interviewed as key study participants.
The data collection was done to understand the health record practices and experiences on health record management, current difficulties and future needs or expectation for good record management practices. The research analysis documents the existing scene of health record management in Nepal and also highlights how and in which way the existing health record management is helping health workers and managers in decision making for quality health service delivery. In addition, it also documents the needs and improvements that the hospital should do to improve health record management in Nepal.
Following data were collected for the study purpose:
Nature of Hospitals Hospital Manager/
Doctors
Health Record Department (HRD)
staffs
Data collection &
handling Staff/Doctors Community
Hospital, Bhaktapur
1 1 1
Private Hospital, Kathmandu
1 1 1
Government Hospital, Darchula
1 1 1
Table 1: Date Collection
In Nepal other than local health facilities, community hospitals, government hospitals and private hospitals are first points of care for patients. These hospitals are the front line of the health information system which helps to identify the patient’s health records as well as treatment procedure to improve the health of the patients. The in-depth interview was carried
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out with each 3 hospital Manager, 3 health record department staffs (HRD) and 3 health workers in three different hospitals (government hospital, community hospital and private hospital). The results were explained based on the in-depth interview with respondents during different management capacity of respondents were involved so it is not possible to say that every findings and statement would include all participants’ feedback.
3.3 Data Analysis
The data collected from the interview was in large amount and therefore it was needed to categorize these data in certain categories and to build the themes and sub themes based on the research question and objectives. As the research questionnaire was formed in definite order, the collected data were transformed to the questionnaire accordingly. All collected data were transcribed into English (when the interviewee responded in Nepali) and coding was done based on predesigned and pre-tested questionnaire. All the findings and quotes were reviewed and coded separately and categorized in different categories and subcategories.
The analysis of data was performed based on the conceptual framework of the study.
Thematic analysis was performed by using deductive methods. Different categories and themes mentioned above were used for the data analysis. These themes were merged according to similarities between them according to research objective and theoretical framework used. A comparison of all three hospitals was done based on the collected information and defined as per themes generated. All of the transcribed data as well as researchers observation and note taken during the data collection plus interesting statements from participants was incorporated in the study as regular findings and rich text quotes were highlighted with comma.
Nine different categories and thirteen sub categories was developed during the analysis as shown below. This was needed to outline the themes that were received after completion of the interview process.
1. Health Record Management Practices 2. Patient Identification and Numbering 3. Discharge / Death Records
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5. Health Data management Data Management
Filing and Storing System of Health Records Policy on Retention of Health Record
List of Medical Record Department Procedure Patient Access to Health Records
6. Medicolegal Cases and Legal Paperwork Medicolegal Cases Handling Practices Patient Information Disclosure Policy 7. Medical Record Department
Health Record Management Committee Staffs for Health Record Management Medical Record Officer’s Department Out Patient Records
Emergency Records
Budget allocated for Health Record Management 8. Challenges in Health Record Management
9. Way forward in Health Record management
After the themes were coded into nine main categories and thirteen sub-categories, I was able to get the overview of how the respondents expressed their answers and the experience they have on the subject matter. The relevant answers received in the interview gave clearer picture of how the health records are managed in hospitals of Nepal and how much these respondents are involved in the health record management process.
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Chapter 4 explores the findings of the research. This section highlights how the results were gathered and categorized into main categories and sub categories. Further it also explains in detail these categories and present the findings in systematic order. The summary of the results are also presented in this chapter which provides the extensive clarity of health record management practice in three different types of hospitals of Nepal.
4.1 Research Findings
This section presents the findings of existing practices of health record management in hospitals of Nepal from the healthcare providers’ views of Nepal. Several themes were identified after the analysis of interviews with hospital managers, health record department (HRD) staffs and health workers (HW). The identified codes were later categorized under different categories and sub categories. The findings of the studies were presented in categories and sub categories with rich quotes of the participants collected during the interviews. The findings were presented in the study as shown in table below
Main Categories Sub Categories and process Health Record Management Practices Types of Data
Patient Identification and Numbering Discharge / Death Records
Quality Assurance & Control
Health Data Management Data Management
Filing and Storing System of Health Records
Policy on Retention of Health Record List of medical record department procedure Patient Access to Health Records
Medicolegal Cases and Legal paperwork Medicolegal Cases Handling Practices Patient Information Disclosure Policy Medical Record Department
Or Human Resource
Health Record Management Committee Staffs for Health Record Management Medical Record Officer’s Department
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Out Patient Records Emergency Records
Budget allocated for Health Record Management
Challenges in Health Record Management Way forward in Health record management
Table 2: Categories and Sub-Categories of Findings
Types of Health Record Management practices:
In all hospitals, both paper and electronic health record management practices were found.
Comparing with private and community hospital, government district hospital were found to have higher rate of using paper-based health records. In private and community hospital they took patient demographic and lab investigation electronically whereas other doctors note, medication, prescription, discharge details are done in paper.
“Both paper and electronic records are available in our hospital. Patients are registered at Out Patient Department (OPD) electronically, lab reports also kept electronically. Doctors
notes, OPD records, IPD & discharge records are paper based.” (Manager, Private Hospital)
Electronic Health Record
In government hospital, internet system is required to maintain the electronic health record. In addition to this, private hospital also mentioned that they need fully electronic set-up for effective record management system. On the other hand, community hospital required no system for electronic health record as they are using traditional process.
None of the hospitals have any funding available for electronic health record. All three hospitals have enough adequate and reliable electric supply at their places.
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Community hospital mentioned that they have written policy developed by the hospital board committee named ‘Hospital Guide’ to manage the different rules and activities. Similarly, government hospital responded that they have government policy and guideline related to health record management. On the other hand private hospitals did not mention about any written policy regarding the procedure.
“We have government made guidelines to manage health records and submit reports. We follow the rules according to the guideline on how to maintain the records” (HRD staff,
Government Hospital)
Patient Identification and Numbering:
Patient Identification
Patient Identification is unique documentation of patient used to identify the patient status, their safety and to create complete record. There were different practices of keeping patient identification number in Nepal.
In community hospital there was practice of keeping patient unique ID number. Similarly, they also keep patient ID during Admission in a patient admission register. In admission register book, patient’s detailed information including medical history; last treatment and doctor name are recorded during the time of admission. In government hospital patient ID assigned on the basis of admission and according to bed used during the admission whereas, private hospital uses continuous serial numbering system for the patient identification.
“Yes, in patient number (ID) is used and as a number. Admission-Reception- Admission book (register). Admission register include patients detailed information and cause of admission
recorded during the time of admission in In-patient department.” (HRD staff, Community Hospital)
“No, we use board in each hospital bed for inpatient.” (HRD staff, Government Hospital)
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“Yes, we assign several numbers to patients at OPD, emergency and referred in case of registration counter. We call serial number or patient number. Unique ID term not used, we
call it Patient ID.” (HRD Staff, Private Hospital)
Although there were different practices of keeping records regarding patient identification but all three hospital mentioned there was no problem in patient identification number in their hospitals. According to community hospital, they search patient ID manually through reports.
Due to less number of patients in government hospital there was not a big deal in patient identification number whereas in private hospital, patient identification is done by searching serial number in the computer.
“No, it is not a problem as we place 100-100 of bundle reports. We can easily find it. It hasn’t been much of a problem in our hospital” (HRD staff, Community Hospital)
“Less number of patient visits at Out Patient Department (OPD) and less no of patient admitted and patient are easily identified. We haven’t faced much problems associated with
patient identification” (HRD staff, Government Hospital)
“Not much patients so far and we use serial number. We also make computer entry and it makes easier to identify patients.” (HRD Staff, Private Hospital)
Medical Record Numbering
Every hospital has their own pattern of keeping medical numbering. The recording register, forms and slips are different in nature. In all the 3 hospitals, form sizes are different based on nature of form and required spaces. Information required by individual hospitals differs according to nature of the information required. Usually community hospital has common size reporting format except in ICU, where they use A3 size register. Similarly, Government hospital also uses different forms with different shape and size. In private hospital out-door patient card, emergency room card and others are different in sizes.
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“Record register is different in Intensive Care Unit (ICU) which is a place to keep severely ill patient for intensive care. We use normally the A3 size register.” (HRD Staff, Community
Hospital)
“All forms are of different size. The size of the register hasn’t been much discussed and the no issue has been reported yet” (HRD Staff, Government Hospital)
“No, Out Patient Department (OPD) card in our hospital, Emergency Room Card, Indoor cards are of different sizes based on the need of the hospital.” (HRD Staff, Private Hospital)
Regarding the medical record design, HRD Staff from community hospital said they took reference from another hospital and designed their forms after required adaptations. Whereas, government hospital said they receive supply of designed and printed form from the government (HMIS section). In comparison to other hospitals, private hospital said they design/change their own forms based on recommendation of doctors and other staffs.
“We use sample reference from other hospital and update it timely.” We have tried to modify our medical record design based on the need of the hospital and also we have many times discussed on how the other hospitals in the city are creating the design. Based on these facts
we keep modifying or updating our designs” (HRD Staff, Community Hospital)
“We use the design of the Government of Nepal, Department of Health Services, HMIS section design, approve & introduction of new forms and supply.” (HRD Staff, Government
Hospital)
“Admin staff/ I designed it as suggested by doctors and other nurses/ paramedical/lab staff’s suggestions. Hospital Director reviews and introduces it. Changes are based on need/
meeting decisions.” (HRD Staff, Private Hospital)
Placement of Medical forms is equally important in hospital. In community hospital, the usual practice of placing record forms is in the folder after the patient’s discharge. However, government hospital responded that they didn't have any practice of medical record folder. In case of private hospital, they keep all forms together when patient is in hospital while after
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discharge they handover OPD, lab and other diagnostic reports to the patient and only keep inpatient records and submit it to medical record person for filing and storage.
“Actually all the forms are kept together during their stay. OPD card and discharge sheet are given to the patient. All other records are kept in hospital.” (HRD Staff, Private Hospital)
In these hospitals, all the staff from relevant department has some responsibility of keeping and managing the health records. In case of community hospital and private hospitals, they considered all staffs should be involved and play role in keeping health records. More responsibility was given to the staffs who were working for medical record management. In government hospital due to unavailability of Medical Record Officer (MRO) staff, a paramedic staff or Health worker were responsible to manage health records.
“We have staffs in our respective department who are responsible for the medical records.”
(HRD Staff, Community Hospital)
“Senior Auxiliary health workers are responsible for the post of medical recorder/ officer because the position is not created till date. He has to do all the jobs regarding health record
and health services.” (HRD Staff, Government Hospital)
“All staffs are somehow responsible, but more responsibility is given to me as record assistant and patient registration staff at counter.” (HRD Staff, Private Hospital)
Findings show that both community and private hospital have staffs to do patient registration at arrival which they called patient number. They use the same number everywhere including in the patient health records. Whereas in government hospital no any practice of health record number was found.
“We use same patient registration number everywhere which makes it easy for our tracking system” (HRD Staff, Community Hospital)
“Individual patient record is considered as health record of that patient in our hospital.”
(HRD Staff, Private Hospital)
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“We do not have any health record number system in our hospital.” (HRD Staff, Government Hospital)
Study also shows that in both community and private hospitals, staff involved in record management also managed admission register in all departments. However, there was no practice of number register in government hospital. In case of community hospital, they keep admission book for the new patients whereas private hospital register patient serial number electronically according to the department.
“Admission books are used for the record management”. (HRD Staff, Community Hospital)
“Electronic serial no. in reception/registration counter is recorded. Also individual OPD department and IPD department wise registration is done.” (HRD Staff, Private
Hospital)
Generally, health records are reserved in admission register book. All three hospitals maintained their admission register. Especially patient details and number were kept in admission register which is also followed in other departments.
“In registration counter all the number and patient’s details are kept together, separate admission register is available at separate department.” (HRD Staff, Private Hospital)
Discharge / Death Records
Findings show that in community hospital they placed health records in separate container in every department. When container is filled, they collected it for recording and storage whereas in private hospital they submit daily discharge report. Apart from this government hospital revealed that they review discharge registry at the end of the month for review and report preparation.
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“We collect the records in a separate box for each department and bring them to storage once they are filled. The boxes are normally filled in appx two weeks or depending on how
many cases we received each month.’ (HRD Staff, Community Hospital)
“…Discharge register is used for once in a month for making reports. These register helps us to create monthly report and help us forecast for the next month” (HRD Staff, Government
Hospital)
Regarding death registration system, in community and private hospital there was system of death registration with details of person, but government hospital mentioned they do not have death register system.
“We have death registration system”. We make sure that the detailed information of the dead person is filled in our registration so that we can provide the information for future needed
references.” (HRD Staff, Community Hospital)
“No death register exists in out hospital.”(HRD Staff, Government Hospital)
“Yes, we issue death certificate, also report it in monthly report with demographic information of the patient.” (HRD Staff, Private Hospital)
Quality Assurance & Control
None of the hospital conducted studies on quality control of the medical record department.
However, at community hospital, they took reference and guidance from other hospitals and updated accordingly. Similarly, as per the need to strengthen the medical record keeping system, private hospital is ready to follow the procedure. Further, none of the hospital conducted studies on quality control regarding the content of the medical record.
“…………. we take reference from other hospital and update timely according to the need.”
(HRD Staff, Community Hospital)
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“No. we do not have the quality control studies yet”. Normally we need the permission or order from upper management level to introduce the system and we haven’t received any
order for this kind of work. (HRD Staff, Government Hospital)
“Not yet. But we can do as needed by strengthening medical record keeping system.” (HRD Staff, Private Hospital)
In government hospital no practice of monitoring/quality check is there, but in community and private hospital both of the respondent said that they periodically supervise the data collection department wise.
“One person is responsible to supervises it time to time, one person supervises each department.” (HRD Staff, Community Hospital)
“Yes, but not very deeply, we just supervise staff to take the record and submit.” (HRD Staff, Private Hospital)
“No monitoring and quality check is available yet. Depending on the situation of hospital I believe it would have been good to have some monitoring on timely basis because I am sure
the hospital will only be benefitted from it” (HRD Staff, Government Hospital)
Health Data Management Data Management
The data of health record from hospitals are particularly used by researchers. In the community hospital some of the related research has been done by medical students though there was no specific disease index. Whereas in government and private hospital none of the person carried out research and used health record for the research.
“Few times. The research is done by nursing staff. We also do not have separate disease index. All put in same one.” This system creates hindrances to the researchers for data
collection (HRD Staff, Community Hospital)
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Similarly, Medical record officer from all three hospitals also highlighted they do not use computer disease or any kind of procedure index at their hospitals. Similarly, findings show that in all three hospitals, they do not have any practice of coded data and used further in their hospitals.
This study shows that in community hospital they have system to keep files in health record section and also in department wise. Apart from this, in government hospital they have online data entry system that is operated at national level and they also keep hard copy records at the hospital. Whereas private hospital mentioned that they do not have centralized or decentralized health record system.
“All the files are kept in same place, department wise register.” Department wise health record register has helped over the years to easy access to the files. (HRD Staff, Community
Hospital)
“Online data entry system exists in our hospital as planned by government, HMIS section.”
(HRD Staff, Government Hospital)
Filing and Storing System of Health Records
According to community and private hospitals, they put all records together by arranging them in serial number and store them together. While government hospital mentioned that they use straight numeric system in master register and follow department wise register.
“We wrap all records and put serial number in the front.” (HRD Staff, Community Hospital)
“We use serial no., keep 100 files bundle together.” (HRD Staff, Private Hospital)
In the entire hospital health record department staff is responsible for filing, sometime they receive help from other hospital staffs, support staffs.
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“Sometimes we use medical students or by Health Record Department staffs themselves are responsible for filing.” (HRD Staff, Community Hospital)
“Senior Auxiliary health workers are responsible for the task of filing.” (HRD Staff, Government Hospital)
“In Patient Department (IPD) staffs collect and deliver discharge files to me. I am responsible for filing; support staff help is needed at times.” (HRD Staff, Private Hospital)
Except community hospital, other two hospitals have not practiced sorting or pre-sorting of health records. However, community hospital has sorted health records in the yearly basis.
“In our hospital we do yearly sorting of health records and start from zero the next year. My experience articulates that this system has been very effective as we do not mix the records
from different years together” (HRD Staff, Community Hospital)
This study shows that in both community and private hospital, there was no problem related to missing files, but government hospital mentioned that they have some problem in missing files. Government hospital also suggested for further improvement for which they have to set up separate room with sufficient space and also suggested that all staffs should be responsible to make records safe during use, handling and storage.
“Yes, there should be separate room for medical recorder. All health staff should be responsible for respective files. There are occasions where the files are missing or
misplaced.” (HRD Staff, Government Hospital)
In community and private hospital, the filing space is sufficient, but in government hospital there is minimal space and no separate MRO position assigned for the work.
“No sufficient space is available for filing. As per my experience, we do not have much infrastructures available to help the task and no MRO post created. There is occasionally
over burden of work and I have to work in emergency and also in medical record department.” (HRD Staff, Government Hospital)
