CHAPTER ONE

Introduction

In today’s global economy and competitive environment, Information Technology (IT) is

becoming a widely accepted tool for multi-faceted development in all fields. Information
Technology (IT) is the bedrock for national survival and development in a rapidly changing
global environment. The use of IT on individuals, organization and society is changing
everything. The growing usage of IT is rapidly spreading through every sector; its permeating
effect is noticeable in institutions, government establishments, business organization, homes
and offices etc. The implication of these developments is obvious for the Nigerian societies in
the sense that traditional way of doing things must give way.

Using Information Technology to manage the administration of intricate information

resources promises significant rewards, such as improved practices and cost savings. Several
developments in IT implementation have taken place in healthcare organizations, with IT
playing an increasingly significant role in its delivery. All these technological developments
have been made in providing effectively functioning systems to healthcare organizations to
improve record management services (Grimson, 2001).

Technology has introduced a new dimension to various fields of human endeavour. It is

helpful in bridging information gap when essential and in creating information gap when
needed (Van Hoof et al, 2006). Incorporating different information technologies (ITs) into the
healthcare system of developing countries is not all about modernizing the health system but
it is about saving life by facilitating communication, practicing evidence based decision,
incorporating e-learning to remote health professionals, using it as a medium to access recent
healthcare information, data handling and processing activities among staffs (ITU, 2012).

The art of preservation and management of health records is an issue that has generated series
on concern overtime because it 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). Therefore, the need to develop and organize new
ways of providing efficient health record services has resulted in a dramatic increase in the
use of Information and Communications Technology (ICT) based solutions in Health Record
Management.

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1.1 Background to the study

Health Information Management is one of the key factors that contribute to the strengthening
of health care delivery in every country. Reliable Health Information Management leads to
timely health policies and planning, which improves the general health status of a country, as
well as, serving as a vital element for individual health facilities in managing and improving
healthcare delivery (Teviu, et al., 2012).

The use of Information Technologies (ITs) in improving the general management of health
records cannot be downplayed. This is affirmed by the ability of ITs to capture, store,
retrieve, analyze and transmit large volumes of health records across various locations
(Norman, Aikens & Binka, 2011).

Yusif & Soar, (2014) are of the view that the adoption of ITs in healthcare delivery, which
could generally be referred to as E-health, has not only been crowed generally as eminent in
improving the reliability and effectiveness of health records, but it has also been gloated for
strengthening healthcare delivery systems through its various tailor-made innovative
applications and program such as the Electronic Health Records. Although the use of ITs in
healthcare delivery is not a new global paradigm, its adoption and promotion has particularly
become relevant in resource constraint developing countries whose healthcare systems are
characterized by severe financial, infrastructural, technical and human resource constrictions.

Mami, (2016) the Nigeria government is investing hugely in IT-based Health Information
Management Systems in an attempt to improve healthcare and the general performance of
public healthcare facilities. The adoption of ITs applications in the Nigeria health sector has
seen huge financial injections not only from government but also other private individuals
like international clinic hospital Kano, Abuja Clinics, and institutions as well as other
international organizations. These count for the numerous pilot ITs projects (albeit other fully
matured projects) across a range of government health facilities in Nigeria and Ghana, some
of which are (Nigeria: Federal Medical Center Asaba, Delta State, International Clinic
Hospital Kano, Abuja Clinics and Ghana: Effia Nkwanta Regional Hospital, Korlebu
Teaching Hospital, Komfo Anokye Teaching Hospital, Tamale Teaching Hospital, Ridge
Hospital and Tema General Hospital. The vision of the Nigerian Government is to ensure the
delivery of quality, affordable and up-to-date health services in an equitable and timely
manner through the enhancement of communication and the use of information for planning,
managing, and delivering health services.

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1.2 Statement of the problem

It has been observed that to receive medical treatment in most of our hospitals, the patients
queue up for several hours from one unit of the hospital to another starting from obtaining a
new hospital folder, or retrieving an old one before consulting a doctor, to the laboratory unit
for lab test then to the pharmacy to get the prescribed drugs and so on. With the manual
processes involved in handling the patient most of them waste the whole day in the hospital.
Very often, patients leave their homes very early in the morning in order to be among the first
group to see the doctor. Otherwise, they may end up wasting the whole day without due
attention. This situation is discouraging to most patients and sometimes forces them to turn to
non-professionals or even resort to self-medication for quick recovery. Finally, the keeping of
folder for each patient manually takes a lot of time and money and some of the information
are redundant. All these have net effect of loss of lives and inefficiency on the part of
management. Therefore, the researcher tend to look to evaluate the impact of information and
communication technology on improving health information management in University of
Ilorin Teaching Hospital Ilorin.
1.3 Objectives of the study

The Broad objective of this study is to evaluate the impact of information and communication
technology in health information management in University of Ilorin Teaching Hospital,
Ilorin, Kwara State, Nigeria.

Specific Objective

i. To examine the prior assessment made by the UITH Ilorin Hospital Management
before the implementation of the system
ii. To find out the challenges faced in use of information technology in health records
management in UITH Ilorin, Kwara State, Nigeria
iii. To examine and proffer solutions on preservation and conservation of information
technology in health records management in UITH Ilorin, Kwara State, Nigeria

1.4 Research Questions

i. What was the initial (preparation) assessment conducted prior to the acquisition and
implementation of the ICT?
ii. What are the challenges being faced in use of information technology into health
records management in UITH Ilorin, Kwara State, Nigeria?

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 iii. What are the probable measures of improving on the usage of information technology
in UITH Ilorin, Kwara State, Nigeria?
1.5 Scope of the study

This research work on evaluation of the impact of information and communication

technology on improving health information management was limited to Health Information
Managers, Nurses, Doctors and Others Health/Medical practitioners in major
department/units, UITH Ilorin, Kwara State, Nigeria.

1.6 Significance of the study

The study will be of great valuable to the policy makers and University administrators of
University of Ilorin Teaching Hospital helping them to appreciate the impact of ICT in
Health Information Management practice. The findings and recommendations of the
study will be of importance to Health Information Management professionals. The
researcher hopes that result of the study may be useful to future researchers with interest
in examining further the impact of ICT in the health facility.

1.7 Operational Definition of Terms

Electronic Records (ER) refer to records that are dependable on relevant machines for
access or reading, which is computer hardware and software such as e-mails, database and
word processing.
Electronic Medical Records (EMR): is the health-related information of an individual that
is created, gathered, managed, and consulted by licensed clinicians and staff from a single
organization who are involved in the individual’s health and care.
Electronic Health Record (EHR) is the aggregate or longitudinal electronic record of
patient health information created and gathered cumulatively across more than one health
care organization and is managed and consulted by licensed clinicians and staff involved in
the individual’s health and care. Included in this information are patient demographics,
progress notes, problems, medications, vital signs, past medical history, immunizations,
laboratory data and radiology reports.
E-Health is an amalgamation of healthcare system and Information Communication
Technology (ICT) to enable better health and healthcare delivery.
Health Information Management (HIM) is an information system that is specifically
designed to assist in the management and planning of health programs, as opposed to delivery
of care.

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Health Information Systems (HIS) is a system that deals with storing patient information
which can be gotten from patient records, surveys, health plans, and a host of other data
sources. It comprise the entire infrastructure, organization, workforce and components for the
collection, processing, storage, transmission, display, dissemination and disposition of
information in the healthcare industry.
Health Information Managers (HIM): Strictly health information managers are
professionals who design and manage health system to ensure they meet medical, legal and
ethical standard (Medical and health service managers, 2016) but for the purpose of this
research, health information managers are all those involved in retrieval, filing of case notes
and who give appointment to patients. This is inclusive of all health records staff
Information Technology (IT) is a broad based term used generally to describe the
techniques and technologies, methods and applications which support activities involving the
creation, storage, manipulation and communication of information (Principally computing
electronics and communications) together with their related methods, management and
applications.
Personal Health Record (PHR) is an electronic application through which individuals can
access, manage and share their health information, and that of others for whom they are
authorized, in a private, secure, and confidential environment.

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 CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This literature review includes the contextual issues and brief historical overview of available
health records management systems in Nigeria. The discussion focused on the infrastructural
requirements for using information technology into health record management practice
alongside the cost implications. A significant portion of the literature review centered on the
Nigerian situation as it relates to the poor implementation of hospital information systems.
Issues highlighted about Nigeria include lack of support infrastructure, corruption and lack of
technical support services.

The proper management of data storage and retrieval of records are imperative in any
organization. In this vein, the system used in keeping records in any healthcare organization
should possess the ability to provide smart search functions, instantaneous and multi-location
access, and ability to virtually integrate data elements stored in geographically disperse
databases (Berg & Toussaint, 2013), as this is the only sure way to ensure better healthcare
delivery. The introduction of EHR in healthcare delivery in recent time is therefore aimed to
achieve these functional aims highlighted above. In spite of these functionalities, EHR in the
healthcare sector is also aimed to trounce the inherent problems associated with paper-based
record management systems that have been used in the healthcare industry for over a century.

Many reviews have been made and published to date on use of information technology into
various sectors and different issues in health record management system in Nigeria. The
implementation of health information technology has become a major priority in the health
care industry due to rising health care costs; escalating concerns for patient safety and
reducing medical errors; focus on improving the provision of evidence-based care; and the
increasing number of regulatory requirements placed on health care providers (Doebbeling et
al, 2006).

Berg & Toussaint, (2013) believed that the health records in most Nigerian health institutions
especially in hospitals has been facing some numbers of problems; these had affected the

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accessibility and utilization of health information in the treatment of people that have health
challenges in those hospitals, as information needed on each patient is not being accessible on
time or is not even available.

In this section, a review of other relevant studies relating specifically to the objectivities of
this study is presented. This section firstly brings to bear the adoption of Information
Technology for the development of health record sector in Nigeria, while considering the
challenges and benefits of using Information Technology into health record management
system. It then proceeds to a review of record keeping (paper and electronic record keeping)
in various health facilities. This section also highlights the benefits and challenges associated
with the implementation of EHR as accounted for by other studies. It then concludes with a
summary and the rationale for the present study (Berg & Toussaint, 2013).

2.2 Theoretical Framework

Currently, a gap in knowledge exists about the exact number of hospital information systems
functionally available in Nigeria, but the subjective data project less than 5% implementation
of any form of hospital information technology in a country of more than 150 million people
(Idowu et al., 2011). The available literature provides a common position among various
authors that disparities exist in the implementation of hospital information systems in
developing and developed countries. Speculated reasons include poor technological and
funding support in developing nations, poor management capacity at all levels that ensures
seamless workflow, and a complex milieu of health care service delivery. Other possible
factors for low implementation include the continual evolution of technology, confidentiality
problems with use of hospital information systems, and the poor technological background of
the Nigerian society (Krishna et al., 2014).

Holden (2009) posited that much research related to adoption of health care information
technology has been a theoretical. In this study, a useful theoretical model is the maturity
model to process improvement originally described in software engineering and used in the
novice-to-expert approach to competency. The maturity theoretical model describes a
modernization framework aimed at the committed use of relevant information technology in a
change process.

Beneficial uses of information and associated technology as it relates to health care

improvement in this model includes monitoring individual and organizational performance,
facilitating information sharing among different health care organizations through a multi-

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agency approach, and empowering individuals by providing relevant information to
consumers, thereby helping them to make informed choices (Gillies et al, 2015).

An additional theoretical standpoint in this study is that in a heterogeneous society as Nigeria

with significant disparity in accessibility of health care facilities between urban and rural
communities, hospital information systems will help to bridge the gap in availability of
patient care. Sammon et al (2009) associated patient data analysis systems (PDAs) with
enhanced storage and analysis of patient data, enabling physicians to reach improved clinical
decisions on patient care. Similarly, clinical information systems capture clinical data to
enhance prompt and efficient decision making.

Sisniega (2010) asserted that the applications of information and communication technologies
(ICT) facilitate ubiquitous and instantaneous communication between organizations and their
stakeholders. Information communication technology enables people and organizations to
achieve a seamless workflow and effective processes through improved interactions.

2.3 HEALTH RECORDS MANAGEMENT SYSTEM IN NIGERIA

The processes used to collect, process, and store patient information to aid clinical treatment
are probably as old as medicine. The formats for collection of patients’ records and the ways
in which this information is used and subsequently stored for future references has continued
to evolve from regular paper note takings to electronic taped records and present-day hospital
information technologies. Wilcke (2018) defined information literacy that affects medical
practice as the ability to identify the need for incorporating information technology.
Information technology infusion that aids globalization refers to the degree to which various
information technology tools integrate into organizational activities.

The growth of computer technology in the 1980s with consequent improvement in

information literacy saw the advent of the first breed of hospital information systems (Keenan
et al., 2009). Earlier researchers in hospital information systems categorized them into three
types: Consumer informatics, medical and clinical informatics, and bio informatics based on
areas of application (Detmer, 2001).

Medical and clinical informatics applications relate directly to health care organizational
processes, structure, and clinical outcomes. Electronic medical records system is a major
medical and clinical information system aimed at the lowering cost of health care therapies
(Svensson, 2012), In its earliest applications, hospital information systems were mostly used

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for patient’s electronic record keeping, but has advanced into almost all areas of medical
discipline. Common applications of hospital information technologies include Computerized
Physician Order Entry, Pharmacy Information Systems, Laboratory Information Systems,
Radiology Information System and Picture Archival and Communication Systems,
telemedicine, and many others as these technologies are constantly evolving (Jain, 2012).

2.3.1 Adoption of Information Technology for the Development of Health Record

Sector in Nigeria

Over the last few decades, there has been significant pressure on hospitals and physicians to
adopt electronic health records system. Thus, the implementation of Information Technology
(IT) has become increasingly common in health record settings. However, the adoption rate
remains fairly low, especially in comparison to hospitals in Europe (Anderson et al., 2012).

The ambitious and challenging healthcare scenario the healthcare providers completely
depend on Health Information Technology (HIT) for timely and instant access to health
information. At any given point of time during patient encounter or afterwards, HIT allows
the provider to collect, store, retrieve and transfer information in and across healthcare
settings. The health sector has always relied on technologies. According to WHO (2014),
they form the backbone of the services to prevent, diagnose, and treat illness and diseases.

Incorporating different information technologies (ITs) into the healthcare system of

developing countries is not all about modernizing the health system but it is about saving life
by facilitating communication, practicing evidence based decision, incorporating e-learning
to remote health professionals, use it as a medium to access recent healthcare information,
data handling and processing activities among staffs (ITU, 2012). Among the different IT
system initiatives in developing countries medical records systems are becoming dominant
with the vision of improving data handling and communication in healthcare organizations
(Davies et al, 2006).

Aljumah et al, (2013) observed that the main problems being faced by hospital authorities in
preservation and management of records in most developing countries include: Use of
outdated forms: Need of constant revision; Shortage of experienced personnel: Need of
trained personnel; Lack of planning in storage of inactive records: Need of effective storage
and control of in- active records; Lack of determination of records retention period: Need of
determination of records retention period. The unwanted records should be destroyed to save
the time and resources; also, Delay in transfer of records: transfer of record entail two stages

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i.e. dating of unimportant records for destructions and ultimate disposal and moving the
records from active to in-active files and from there to the storage area.

Lack of efficient health information systems also bring about the fragmentation of data as
there is no common or central format for collecting or storing whatever data or information is
retrieved from the patients. To ensure that HIS contribute to improved health services, it is
essential that policy makers and health system managers utilize available information for
ongoing monitoring of plans and programs, as well as for resource allocation purposes
(Francis et al, 2010).

Electronic information can be viewed as the raw material, which can then be made available
to end users via a range of methods and platforms. Therefore in Nigeria there is a dire need to
strengthen the health information system through the provision of appropriate infrastructure,
and the establishment of mechanisms or procedures for collecting and analyzing health data
to provide needed information (WHO, 2010).

2.3.2 Challenges of Incorporating Information Technology into Health Record System

Digital projects are expensive. Many health practitioners understand the benefits of hospital
information technologies, but they do not find easy justification for the cost. Digitization of
records requires enormous funding due to frequent hardware and software upgrades, and
increasing cost of subscription to electronic databases, this makes them to be easily by
information seekers globally (Jain, 2012). The upgrade and running cost burden is remarkable
and outside the reach of small hospitals and health care trusts. Compounding the cost issues,
the lack of interoperability of information systems marketed by different vendors is a
significant concern.

Management of electronic health record systems is constantly evolving with different systems
currently available to service various clinical applications, facilitate strategic decision making
and improve administrative workflow (Hikmet et al., 2017). Due to inadequate skills in
information technology, many traditional librarians, record keepers and archivists are
conservatives and have phobia for computers. Because of generation gaps between the new
and old professionals, computers are perceived as a threat to their status as experts. Problems
with Interoperability do not allow seamless retrieval of patient information across different
operating systems. Patient clinical data may be accessed only in hospitals with compatible
information systems, thereby hampering the key benefit of easy and universal access to
patient data that the technology is meant to support (Arrow et al., 2011). Other key concerns

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constituting major limitations of hospital information technologies include wrong
identifications, wrong or incomplete information documented in hospital systems, the
possibility of making changes to patient information by unauthorized persons.

Georgiou, et al. (2015) asserted that hospital information technologies eliminate some aspects
of human interaction among staffs, thereby hindering workplace collaboration and cohesion.
Keenan, et al. (2006) concurred that the human element is still very important in health care
delivery and technology is just a tool in the hands of trained personnel. Other economic
limitations of incorporating information technologies into health record system includes

1. The inability to ascertain an accurate return on investment

2. Problems with appropriate reimbursement for technology use, and
3. Focus on technological issues at the expense of health care services and business
concerns (Ward et al., 2016).
2.3.3 Benefits of Incorporating Information Technology into Health Record System
ICT helps to improve on the seamless workflow among people and the organization; effective
processes can also be achieved through efficient and effective interactions. Samoutis, et al.
(2007) observed that computerized systems increased work efficiency and improved the
quality of care to the patients served. Recent health care debates reinforced the demands for
reimbursement that are associated with quality of care outcomes. Implementing the right
systems to incorporate the appropriate components is a necessity.
Weiner (2013) opined that network effectively among themselves with the use of electronic
health technology, by allowing the review of patient’s treatment online and to accurately
prescribe the necessary drugs. The workflow among the various healthcare entities is
improved upon by the healthcare information system and also, patient’s access to healthcare
increases. The communication between organizations and stakeholders is facilitated by the
application information and communication technologies.
Another benefit of ICT is in aspect of intra-organizational communication as mostly
interpersonal. Synchronous interruptive communication is recognized as a primary source of
inefficiency and error in healthcare. Information about patient can be easily read by
healthcare providers through the computer, the information is always available, cannot be lost
or left sitting on a desk. The information is available to users in different locations. For record
keeping, this can be explained in terms of patient laboratory or any clinical test results in the
hospital and can be added to patient’s record as soon as the test result is complete and ready
(Brudnick Centre Report, 2013).

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Electronic Health (E-Health) facilitates healthcare to reach remote population which are not
properly serviced by traditional means. There is evidence that having electronic health
records that are readily accessible can reduce errors that result from gaps in knowledge
regarding past medical history, allergies, or medications, especially when patients are being
treated by multiple providers. Additionally, there is evidence that decision support tools can
integrate electronic patient information directly into the provision of care and can reduce
errors of omission that result from gaps in provider knowledge or the failure to synthesize
and apply that knowledge in clinical practice (Shekelle et al, 2012).

2.4 Record keeping in healthcare delivery

There are two major means of keeping medical or health records of patients in any healthcare
delivery facility. These are paper-based record keeping systems and EHR keeping systems.
These record systems (whether paper-based or electronic) accomplish two crucial functions
(Berg, 2010). Firstly, health record systems helps in the accumulation of data gathered during
the course of a patient trajectory, which in turn help create an ‘external memory’ for future
use. Secondly, health record helps in coordinating activities and events at various
departments and even other geographical locations (Berg & Toussaint, 2013).The following
sub-section further throws light on these categorizations.
2.4.1 Paper Base Record Keeping in Healthcare Delivery
The healthcare industry has widely made use of paper based record system as a means of
keeping patient’s medical information for the past two hundred decades. Although, it has
helped the entire healthcare delivery system a great deal from antiquity to date; Coeira (2012)
observes that, paper based record inherently pose some corporeal and informational
challenges that makes it difficult for it to be sustained as a proper means of record keeping in
healthcare delivery. Thus according to many practitioners, paper-based system alone is just
not good enough anymore and they justify this by citing various challenges of the paper
record which include; Difficulty in accessing and sharing medical history of patients: Paper
based record system makes it extremely knotty for medical professionals at different
geographical location to access previous medical information of patients for proper diagnosis
or treatment regimes. It is true that paper-based medical information of patients can be
conveyed with the aid of fax machine, telephone conversation, and even via courier services
or through the post, but these modes of transmitting medical information have the potential
for the misreading or mishearing of data, loss of information and delay (Institute for
Medication practices, ISMP, 2000). Even in cases where health professionals at various

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geographical locations get hold to previous medical information of patients, it is intimates
that reconciling the medical data could still be impossible (Coeira, 2012).
Coeira, (2012) believed that different interpretations are sometimes given to the same
medical records as making sense from the medical data often vary among professionals due
to illegibility or improper spelling of a medical terminology.
Improper Organization of Patient Records: Following from the preceding point, paper based
records could lead to improper certification of medical records. With paper based records
there is high risk of assigning wrong codes or symbols to medical files, which in turn makes
it extremely difficult to locate these same files in a future date. Again, retrieval of medical
file from a pile of health records according to Warshawsky, et al., (2009) can also be
daunting and time consuming. These improper classifications of medical records impede
access to data and sharing data for proper healthcare delivery.
2.5. Electronic Health Record (EHR) In Healthcare Delivery
2.5.1 Meaning of EHR and Its Components
There exist numerous names with its accompanying acronyms for describing the use of
computer systems or ICTs in healthcare delivery. Some of the names could be mentioned as
Electronic medical record (EMR), electronic patient record (EPR), computerized medical
record (CMR), computer-based patient record (CPR), and electronic health record (EHR).
These lexicons are often used to mean the same thing but there could still be some minor
differences in the meanings depending on the defining country of origin, health sector,
professional discipline, and period of time (Nøhr, 2016). In giving meaning to consistency,
this study prefers to adopt electronic health record (EHR) to describe the ICT implemented in
the hospital. Again, Nøhr (2016) noted that the term ‘health’ in EHR refers to a person’s vital
data independent of any specific periods of being a patient, therefore the use of EHR is
deemed as most suitable for this study.
1. Meaning
Many writers have ascribed various definitions to EHRs; however the internationally
recognized definition of EHRs was given by the International Standard Organization (ISO).
ISO (2005) defined EHRs as “a repository of information regarding the health of a subject of
care, in computer processable form”. This definition narrowly focuses on only the structure
of EHR systems, therefore Hayrinen, et al., (2018) sought to explain EHRs by broadening the
focus given to EHRs in the ISO definition. EHRs should be construed as comprising of
retrospective, concurrent as well as prospective information which has the primary objective
of supporting continuous, efficient and quality integrated healthcare delivery. Luo (2013) also
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asserts that EHRs go beyond just the electronic version of the paper based record to
encompass the whole management of data required for patients’ care.
2. Components of EHR
Tang (2013), has noted that an effective EHR system: should have the capacity of storing
patient health information and data longitudinally; should enable results generated from the
system to be managed proper; also enables the facilitation of electronic communication and
connectivity; it should provide patient support and help in administrative processes and
report.
Nøhr (2016), also highlights the common components of EHR as:
1. Clinical Documentation: EHR should enables health professionals to better handle
progress notes of their patients either as free text directly entered into the system or by
predefined structured notes.
2. Physician Order Entry (POE): EHR should also allow for ordering diagnostic test and
medication in a standardized and formalized way. Other EHR systems provides for
checking drug interactions and alert for patient allergy.
3. Booking service: An EHR system allows for patients to book appointments with their
medical professionals be it face to face or online.
4. Communication/Messaging: EHR systems should also enable the exchange
communication between various hospitals, General Practitioners, pharmacies, and
laboratories.
5. Results Management: EHR systems also facilitate the assaying of medical results. The
system is should be able to show some warnings to abnormal results. The system should
also depict trends of a particular result.
6. Charge Capture/Billing: EHR makes it easier to track expenses owed to the facility by
virtue of the health service provided to the patient.
7. Disease Management: EHR also help in management of chronic diseases, by allowing
health professionals to access data to assess whether or not disease is been managed
properly.
8. Management of security issues: All EHR systems have special features that help manage
authentication and authorization of users.

Further, Coeira (2012) also provides various components of EHR, which could be
illuminated, graphically from Fig.1 below:

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 Sou
rce: Coeira, 2012.

2.5.2. Structure of Electronic Health Records

In explaining the structure on EHR system, this study will adopts the structure of EHR
system in Dickinson, Fischetti and Heard (2004). The writers identified three (3) structures or
functions of every effective EHR system and they classified these structures as direct care
functions, supportive requirement and Information Infrastructure. This could further be
explained by the aid of Figure 2 below.

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2.6 The Direct Care Functions of an EHR

The direct care function of every EHR system according to the writers, concerns itself with
the carrying out the functions associated with general clinical tasks. And it involves the
capturing or generation, storage, management, retrieval and communication of health
information that are directly definable with the provision of healthcare. As Dickinson et al.
(2014) opined, the direct care function of EHR ensures the delivery of everyday healthcare to
patients. These include functions such as diagnosis, goal setting on patient management,
planning and carrying out interventions, examination and evaluation of results. It also
includes stand-alone reminders or alerts which provide prompts for contraindications and
wrong prescription of medication to patients.

The direct care function of an EHR also provide task tracking to ensure timeliness in the
provision of care. Hayrinen et al. (2018), however, were of the view that referral; patient
present complaint and past medical history; physical examination; diagnosis; tests;
procedures; treatment; medication and discharge are some of the commonly known Direct
care functions of an EHR.

a. The Supportive Function

The supportive functions of EHR systems are those functions that are not directly related to
the provision of healthcare but are subsidiary direct provision of healthcare though relevant
for the overall delivery of health care (Dickinson et al., 2004). The supportive functions seek
to improve quality healthcare delivery through the provision of inputs for medical researches
and promotion of public health. It also provides assistance for general administrative and
financial management (Dickinson et al., 2004). Examples of these supportive functions are
optimizing patient bed assignments, provision of health guidelines and resources available,
administrative and financial coding assignments as well as the provision of providers’
location in the facility.

b. The Information Infrastructure Function

The function of EHR as an Information infrastructure, relates to the provision of technical

groundwork for the successful achievement of the direct care functions and the supportive
functions. EHR thus becomes the force which propels the well-functioning of both direct and
supportive functions. According to Coeira and Clarke (2014), it involves security, which
entails controlling access and privacy of data. It also involves interoperability or the exchange

16
of clinical and administrative information through standard-based solutions as well as the
sharing of information and records across management and various units.

2.7 The Hybrid Health Record System

In an empirical study conducted in the US by Varga (2011), it was noted that although EHR
is needed to aid in the automation of paper based health records, the complete migration to
EHR system; and thus the consequent elimination of the cosmic majority of paper in the
delivery of healthcare, will take at a minimum of 10-15 years or potentially many years
longer. The study again noted that high percentage of healthcare professionals will continue
to receive health information from patients in the form of paper documents for some long
time to come, even if healthcare professionals themselves convert to an EHR system.
Therefore many healthcare facilities are now combining the use of both EHR systems and the
paper based records systems. This is nonetheless, not exclusive to Varga’s study amongst US
medical professionals but the same phenomenon of combing paper based health records with
EHR has been observed by some writers in the implementation of EHR systems
(Adjorlolo&Ellingsen, 2013).

Kalra and Ingram (2016) sum it all up by instigating that; “Clinical care increasingly requires
healthcare professionals to access patient record information that may be distributed across
multiple sites, held in a variety of paper and electronic formats, and represented as mixtures
of narrative, structured, coded and multimedia entries”.

2.8 Benefits of Electronic Health Records

EHR are highly configurable, and may be adjusted rather comprehensively for different
groups of staff and departments (Bossen, Jensen &Udsen, 2013). These set of characteristics
are itself important contributing factor to the success of EHR implementation (Ibid). But
previous studies conducted by Nah, Lau and Kuang (2011) as well as Ludwick and Doucette
(2009) in seven different countries illustrate that successful implementation of EHR largely
depend on a wide range of contextual and organizational factors (Bossen et al., 2013). And
for this reason, other merits of EHR deserve further elaborations. From the perusal of
literatures, benefits of EHR could be largely grouped under the following headings; Improve
quality of care, Enhance productivity and efficiency, Improved Care Coordination and
Communication, Reduction of cost, and Protection of Privacy of patient records.

17
2.8.1 Improve Quality of Care

The EHR system, when successfully implemented advances and improve the access to
precise and up-to-date health records thereby strengthening the quality of care given to
patients (Bossen et al., 2013; Boyer, Samuelian, Fieschi & Lancon, 2010;
Khalifehsoltani&Geremi, 2010). EHR systems are able to improve quality of patient care
through greater access to health information, which leads to the reduction of medical errors
which were largely associated with the paper-based record systems. Quality of patient care is
also reflected in reduction of test result wait times and the general reduction in patient wait
times in the health facility. In an empirical study conducted by

2.8.2 Enhance productivity and efficiency

Anecdotally, health professionals who operate the paper-based records, habitually spend most
of their time completing paperwork at the expense fulfilling their core duties of giving care.
So a lot of time is spent in sorting out duplicate records, and finding records that are not
available for days or weeks. The implementation of EHR systems in most health facilities has
largely decreased the paperwork for clinicians. This has in turn reduced record-keeping time
thus leading to the optimization of workflow efficiency and increase in the general
productivity of health professionals (Erstad, 2013).

Similarly, evidence abound that e-health tools and for that matter EHR have positive effect
on users (Bedeley&Palvia, 2014). Thus users of EHR are more inclined to become well-
informed, better supported, and have improved behavioural outcomes, as compared to non-
users of EHR in the same health facility.

2.8.3 Improved care coordination and communication

In a study by Smith et al. (2015), it was reported that one out of every seven hospitalizations
is as a result of missing clinical or health information. This is because health records of
patients; like test or diagnosis results and other significant data, are often not available when
needed, or are often mislaid, and even in some cases, completely missing (Ibid). EHR thus
reduces the likelihood of misplaced and lost records, which ensure that health records of
patients and other vital patient data are readily available when needed. This enables health
professionals to have access to better information at the various healthcare delivery points
and departments. Furthermore as observed by Burton, Anderson and Kues (2014), EHR

18
advances an improved level of communication and facilitates overall improved coordination
of care, over and across different health facilities.

That said, the built-in email feature of many EHRs also result in enhancing communication
by allowing staff of various hospitals the ability to communicate with each other from any
department or work station (Erstad, 2003; Menachemi & Brooks, 2006). Again, these email
feature also allows for instantaneous and real-time communication amongst health
professional (Menachemi & Brooks, 2006) and this provides the ability to concurrently
complete tasks by clinicians at various locations thus leading to saving of time.

2.8.4 Reduction of cost and enhanced revenue

The general cost of providing healthcare is on the increase partly because of the inefficiencies
of paper-based work. Manual processes such as expenses incurred for the transcription of
physicians’ dictated notes, pulling, filing, and maintaining charts together with the cost of
maintaining the storage of health records are some of the identified cost associated with the
paper-based records (Cisco Systems Inc, 2011). The introduction of EHR in many health
facilities has however resulted in the reduction of supply and printing cost. Hence the cost
incurred in initiating and maintaining paper health records including clerical supplies, cost of
paper, and printing costs are squashed or reduced when EHRs are used.

2.8.5 Privacy of patient records

EHRs ensure that maximum protection is given to patients’ information, which may be very
sensitive. Health records contain immense quantity of sensitive information, such as fertility
and abortions, emotional problems, sexual behaviours and diseases, substance abuse, and
physical abuse (Nemati & Jacks, 2012). Hence when access to this kind of information are
uncontrolled, it can be injurious and detrimental to the wellbeing of a patient. EHRs,
however, ensure that patient’s records are electronically kept behind login passwords or even
biometric sensors. It also ensures the tracking of providers that accesses patient information
in the system. Thus EHR does not only ensure compliance with privacy regulations but also
provides pliant security measures to protect patient information across the entire wired and
wireless environment.

2.9 Challenges of electronic health records implementation

The progression and sequence of EHR, particularly in developing countries’ health facilities
has never been an easy undertaking as there are many peculiar factors impeding the

19
progression and diffusion of such technologies (Bra, Monteiro & Sahay, 2014). But the point
ought to be made fiercely that challenges of EHR implementation in developed countries,
somewhat differ from the challenges of EHR implementation in developing countries. The
works of Sood et al. (2010) titled “Electronic Medical Records: A Review Comparing the
Challenges in Developed and Developing Countries” is a clearer manifestation of the
differing challenges of EHR implementation in developed and developing countries. This
section of the work thus, would be much more interested in the challenges of EHR
implementation in developing countries owing to the research objectives.

Khalifehsoltani and Gerami (2010), in their study obtained a model, which considers the
challenges facing E-Health in Developing Countries. This model included challenges relating
to six areas of Technology and Operational; Social and Cultural; Native Environment; Legal;
Policymaking; and Financial. However, their model had a general outlook of e-Health, which
EHR is just a fraction. Therefore upon a further review of other works regarding the
challenges of EHR implementation in developing countries, some peculiar issues that affront
EHR implementation in developing countries were discovered. Inadequate Electric Power
Supply; Lack of ICT Infrastructure; lack of basic ICT knowledge/skills; Poor Internet
connectivity; financial issues; and Resistance to New Technology were identified broadly
(albeit others) as the major challenges that hinder the successful implementation of EHR is
developing countries like Nigeria.

2.10 Usability and User Satisfaction

Generally, the effective use and the general satisfaction with respect to EHR on the part of
users is a prerequisite for a successful implementation of EHR systems in any healthcare
facility (Coeira, 2012). Usability of EHRs has also been identified as one of the key
barricades to the adoption of EHRs. Hence Perednia and Allen (2009), in what could be
described as a much detailed review of telemedicine applications, emphasized that the
definitive success of EHR hinges on the ability of health facilities to address managerial
challenges, which include user technology acceptance (Chau & Hu, 2012).

These conclusions invariably led Chau & Hu (2012) to assert “given the potential impact of
telemedicine technology, it is therefore important to investigate factors essential to its
acceptance by individual physicians”. Usability testing should therefore be an unambiguous
element in the pre-purchase assessment of EHR. Usability as a term connotes the
characteristics of human–computer dealings or interactions in a system. Therefore, to

20
describe an EHR system as having good usability means that the system is easy to learn and
remember, efficient to use, generates very few errors, and leads to great satisfaction on the
part of users.

21
 CHAPTER THREE
RESEARCH METHODOLOGY

3.1 Research design

The research design that was adopted for the purpose of this research work is descriptive
survey design.
3.2 Target Population
This research work focused on the staff currently in the department of health information
management, University of Ilorin Teaching Hospital. The populations as early mentioned
include the Health Information Management professionals.

3.3 Sample size and sampling techniques

Complete enumeration sampling technique was adopted using all the one hundred and twenty
(120) respondents within the target population. This method ensures equal chances is to every
respondents to respond to administered questionnaires.

3.4 Data collection instrument

The instrument for data collection for this research was structured questionnaire. The
questionnaire consists of two sections A and B, Section A demographic information while
section B comprises research related questions.

The drafted questionnaire was subjected to the advice, thorough scrutiniza`tion by the
supervisor while the necessary corrections were made``.

3.5 Validity and Reliability

The instrument used was judged reliable through test-retest method using a pilot study which
made up of one hundred (100) respondents who were given questionnaire to respond. This
was done so outcome was obtained thereby establishing the instrument reliability.

3.5 Data collection procedure

The procedure that was used for this study was administered questionnaire and immediate
collection from the respondents to ensure 100% response rate.

22
3.6 Presentation of data analysis
Data collected was presented using simple arithmetic percentage and table while suitable
statistical analysis was used to analyze the gathered data.
3.7 Ethical Consideration
The researcher obtained a letter of introduction from the school which was taking to
University of Ilorin Teaching Hospital where I was referred to Ethical Review Committee
who gave permission to use Health Information Management Department of the Hospital as
my case study.

23
 CHAPTER FOUR
DATA PRESENTATION ANALYSIS FINDINGS AND DISCUSSION

4.1 INTRODUCTION
This chapter contains the findings obtained from the field survey. The data for the study were
collected through the use of questionnaire which was distributed to the respondents and
analyzed in order to have insight information on the use of information technology in health
records management in UITH Ilorin, Kwara State, Nigeria.
The collected data were analyzed so as to obtain and discuss its findings especially as it
relates to the researcher′s questions and objective using descriptive statistics. This analysis
involves the collation of data received from administered questionnaires and conducted
interviews.

4.1.1 DEMOGRAPHIC INFORMATION OF RESPONDENTS

TABLE 4.1: GENDER OF RESPONDENT

Respondent Frequency Percent
Male 30 30
Female 70 70
Total 100 100

It was seen that majority of the respondents 70 (70%) were female while about quarter 30
(30%) were male in the record department.

TABLE 4.2: Cadre of respondents in UITH, ILORIN

Health/medical practitioners frequency Percent %
Health Information Officer 70 70
Health Record Technicians 20 20
Health Record Assistant 10 10
Total 100 100

24
 Cadre of responmdents in percentage
80

70

60

50

40
70
30

20

10 20
10
0
HRO HRT HRA

HRA

It was shown from the above table and chart that 70 (70%) were Health Records Officers, 20
(20%) were Health Records Technician while 10 (10%) were Health Record Assistance.

TABLE 4.3 ACADEMIC QUALIFICATION OF RESPONDENT

Number of respondent Percent (%)
ND 45 45
HND/B.SC 52 52
M.SC 3 3
P.HD 0 0
Total 100 100

It was seen that 45 (45%) of the respondents were ND holder certificate, 52 (52%) had
HND/B.sc while 3 (3%) had M.SC

TABLE 4.4 RESPONDENT YEARS OF WORKING EXPERIENCE

Number of respondent Percent (%)
25
 0-7yrs 32 32
8 – 15yrs 50 50
16 – 23yrs 15 15
24 – 31yrs 3 3
32 and above
Total 100 100

It was indicated from the above that 32 (32%) of the respondents had 0-7years working
experience, 50 (50%) had between 8-15years working experience, 15 (15%) had 16-23years
working experience while 3 (3%) had 24-31 working experience.

Table 4.5 Research Question: Initial (preparation) assessment conducted prior to the
acquisition and implementation of the HER.
Characteristic Number Percentage
(100) (100%)
Were you involved in the decision to introduce the
electronic health records?
Agree 55 55
Disagree 40 40
Undecided 5 5

Did you have any influence on how the system should

work before it introduction
Agree 10 10
Disagree 80 80
Undecided 10 10

Were your suggestions followed in the design and

implementation of the system?
Agree 10 10
Disagree 90 90
Undecided 0 0

Did you receive any training on the EHR before it

implementation
Agree 80 80
Disagree 15 15

26
 Undecided 5 5

Was the training adequate for you to use the EHR

Agree 70 70
Disagree 25 25
Undecided 5 5

Do you think the implementation of the EHR was well

planned
Agree 65 65
Disagree 20 20
Undecided 15 15

Table 4.5 above shows the initial (preparation) assessment conducted prior to the acquisition
and implementation of the EHR. The more than half (55%) were involved in the decision to
introduce the electronic health records; majority (80%) of the respondent did not have an
influence on how the system should work before it was been introduce. Almost all (90%)
respondents’ disagreed that their suggestions were not followed in the design and
implementation of the system. Almost all (80 %) of respondents receive training on the EHR
before it implementation. Majority (70 %) of respondents were training adequately for use of
EHR. Also, more than half (65%) of respondents think the implementation of the EHR was
well planned.

Table 4.6 Research Question: Challenges being faced and solution proffer in use of
information technology into health records management in UITH Ilorin, Kwara State,
Nigeria
Characteristic Number Percentage
(100) (100%)
The ambitious and challenging healthcare scenario the
healthcare providers completely depend on Health
Information Technology (HIT) for timely and instant

27
access to health information.
Agree 75 75
Disagree 25 25
Undecided 0 0

The unwanted records should be destroyed to save the

time and resources
Agree 50 50
Disagree 40 40
Undecided 10 10

Management of electronic health record systems is

constantly evolving with different systems currently
available to service various clinical applications,
facilitate strategic decision making and improve
administrative workflow
Agree 75 75
Disagree 25 25
Undecided 0 0

ICT helps to improve on the seamless workflow among

people and the organization; effective processes can also
be achieved through efficient and effective interactions.
Agree 80 80
Disagree 20 20
Undecided 0 0

There is evidence that decision support tools can

integrate electronic patient information directly into the
provision of care and can reduce errors of omission that
result from gaps in provider knowledge or the failure to
synthesize and apply that knowledge in clinical practice
Agree 95 95
Disagree 0 0
Undecided 5 5

Do you think the paper-based medical information of

28
 patients can be conveyed with the aid of fax machine,
telephone conversation e.t.c
Agree 55 55
Disagree 25 25
Undecided 20 20

EHR should enables health professionals to better

handle progress notes of their patients either as free text
directly entered into the system or by predefined
structured notes
Agree 100 100
Disagree 0 0
Undecided 0 0

Lack of ICT Infrastructure and knowledge/skills are

major challenges that hinder the successful
implementation of EHR UITH, Ilorin
Agree 95 95
Disagree 5 5
Undecided 0 0

Table 4.6 above shows the challenges being faced and solution proffer in use of information
technology into health records management in UITH Ilorin, Kwara State, Nigeria. The more
than half (75%) were ambitious and challenging healthcare scenario the healthcare providers
completely depend on Health Information Technology (HIT) for timely and instant access to
health information; majority (50%) of the respondent agreed that the unwanted records
should be destroyed to save the time and resources. It is seen that (75%) respondents’ opined
that management of electronic health record systems is constantly evolving with different
systems currently available to service various clinical applications, facilitate strategic
decision making and improve administrative workflow. It is shown that (80 %) of agreed that
ICT helps to improve on the seamless workflow among people and the organization; effective
processes can also be achieved through efficient and effective interactions. Almost all (95%)
of respondents agreed that there is evidence that decision support tools can integrate
electronic patient information directly into the provision of care and can reduce errors of

29
omission that result from gaps in provider knowledge or the failure to synthesize and apply
that knowledge in clinical practice. Also, many (55 %) of respondents think the paper-based
medical information of patients can be conveyed with the aid of fax machine, telephone
conversation. All (100%) agreed that EHR should enables health professionals to better
handle progress notes of their patients either as free text directly entered into the system or by
predefined structured notes. It was indicated (95%) agreed Lack of ICT Infrastructure and
knowledge/skills are major challenges that hinder the successful implementation of EHR
UITH, Ilorin

4.2 Discussion of Findings

The findings from the study is as follows:
The result revealed that needed health records are available in the hospital even though the
proportion of availability varies.
The analysis of mechanism put in place for effective management of health records in
hospitals revealed that care in handling hospital records, Confidentiality of records, security
of records and avoidance of water contact/bad weather are major mechanism employed in the
hospitals.
Poverty, poor government funding, lack of appropriate government policies on adoption of
health care technologies, human capital flight to developed countries, the low technological
base of the country, inadequate electricity supply, and corruption are among common
assertions that authors believed are responsible for poor adoption of information system.
Adapting Information Technology (IT) to medical record management reduces the cost of
healthcare delivery through reduce administrative bottlenecks. The convenience this kind of
system will give to physicians, patients and hospital administrator especially in developing
world cannot be quantified.
The high cost of implementation of all the components of information technology systems
appears to be a global challenge in health record system.
Hospitals, health care regulatory bodies and the Health ministries in Nigeria will take
advantage of innovations that are becoming available through internet solutions to improve
healthcare system. It is also hoped that synergy among health care stakeholders will produce
results expected from health care organizations.
The major challenges faced in handling health records in hospitals are poor funding,
inadequate computer and other ICT devices, poor skill in computing, harsh environmental
conditions, lack of preservation and conservation policy.
30
31
 CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction
The rapid advance of IT in healthcare settings has accentuated the importance of
addressing the shortcomings of current health record integration practices. This matter is
made worse by the regulatory gap between implementing new and emerging ICT, and
managing the security risk the latter represents. Other problems include poor data quality and
fragmentation, budgetary constraints, irreconcilable systems architecture, a history of
incompatible data standards, confusing privacy jurisdictions and a lack of access to proven
evaluation results. This research argues that it is of crucial importance that technology
innovation in health is associated with the incorporation of Information Technology (IT) for
establishing secure health record integration.

5.2 Summary
The analysis of mechanism put in place for use of Information Technology (IT) in health
records management in UITH, Ilorin revealed that care in handling hospital health records,
confidentiality of health records, security of health records and avoidance of water
contact/bad weather are major mechanism employed in the hospital. The major challenges
faced in use of IT in health records managements in surveyed hospital are poor funding,
inadequate computer and other ICT devices, poor skill in computing, harsh environmental
conditions, lack of preservation and conservation policy.

5.3 Conclusion
Use of Information Technology (IT) in health records management is an integral part of
medical/ healthcare service delivery as it goes a long way in enhancing better service delivery
as well as serving as a basis for following patient health trend overtime. It also serves as a
basis for effecting referral service. Hence effort should be made to ensure regular
preservation and management of records in medical centers/hospital.
The knowledge and skill of IT should be used on the hospital staff through training and re-
training, formulation of health record management policies, infrastructural development,
proper funding, computer skill training, etc as these would help in ameliorating the problem
of poor hospital record preservation and management and its attendant’s negative impact on
health care delivery.

32
5.4 Recommendations
In view of the above findings, the following recommendations were made for management of
the institutions and to the entire health institutions in kwara and Nigeria at large. The
following aspects should be improved for better operation of health information management
in the future:
1. Management of health institutions should inject more financial resources into the
organization in order to solve the problem of inadequate funding of the health records
management. It takes real money to acquire and maintain good health records
management.
2. Capital should be injected into provision of infrastructure and acquisition of modern
equipment that would facilitate and sustain the general health condition of their
patients. These could help in saving cost and manpower on the long run.
3. Management of health institutions should intensify their efforts in encouraging their
health workers to maintain good handling care of records; while some of the paper
based records should be microfilmed in order to sustain their durability.
4. Management of the health institution need to training the health/medical practitioners

5.5 Limitation of the Study

During the processing of the project, the researcher faced with a lot of physical problems.
These problems includes:
The researcher seriously faced with the problem of data collection, which helps in building
the manuscript. Because information is the tool of business for solid data collection or
material. So, inability to get materials on time really set my project back. Actually, it took me
more than five months to gather enough information needed for this project.
Also for collection of data from my case study a lot of money is spent on transportation
(Ibadan to Ilorin and Ilorin to Ibadan). Hence for one to be effective in this project, money
must be involved.
Finally, the major limitations of this study were time, financial constraints and poor response
by some health/medical practitioners fearing that computers may take over the practice of
medicine which in advance, they may lose their jobs. For this reason the researcher is
recommending compulsory information technology training for all the medical practitioners
to enable them cope with the current trend in information technology.

33
5.6 Area of Further Studies

It is recommended for further studies to examine country specific policies and its effect on
the implementation of EHR especially in the context of developing countries such as Nigeria.
This would help unearth the limitations and barriers created by national policies and
regulations on ICT systems’ implementation in both developed and developing countries. It
would also help to determine the national readiness for EHR in developing countries.
It is also recommended that future studies evaluate the impact of EHR from the patients’
perceptive. This would help reveal whether or not the intended benefits of the implemented
EHRs to patients are actually realized.
From the identified limitations to the adopted study approach, it is recommended for further
studies to adopt both quantitative and qualitative research approaches in similar studies to
generate diversified responses from participants.

34
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