Medical records preservation strategies in improving healthcare service providers’ access to patients’ medical histories in the Limpopo hospitals,South Africa

Abstract

Preservation of medical histories records is very crucial to patients’ healthcare quality since when preservation is not being discharged properly; medical histories records are either inaccessible or difficult to access, which has a detrimental effect on the healthcare services provided to patients. The purpose of the study was to investigate strategies for the preservation of medical records and to recommend a framework that healthcare institutions may use to ensure that they have their patients’ medical records/histories at their fingertips (readily available). Stratified random sampling was used in the study to collect questionnaire data from records management officials and heads of clinical, nursing and records management units at 40 state hospitals in the province of Limpopo in South Africa. The data was augmented with observation, system analysis and document analysis. The study revealed that the preservation of medical records in public healthcare institutions in Limpopo was very chaotic, to the extent that access to patients’ medical histories was not always a possibility. Healthcare institutions need a framework for medical records preservation throughout the process of healthcare service delivery, to avoid chaotic healthcare service that eventually hamper health of the patients. The study provided a generic framework that may be localised as a centre of benchmark for healthcare institutions to suit their own environmental needs.

Keywords

Healthcare institutions healthcare services Limpopo province medical history medical information Medical records public sector records preservation South Africa

Background

The major purpose of ensuring the appropriate preservation of records systems in healthcare institutions is to ensure that healthcare professionals have information at their fingertips, which means getting information in good time when healthcare services are delivered (Luthuli and Kalusopa, 2017). In most instances, hospitals and healthcare professionals struggle to access the medical information in their custody, because the records are not properly preserved for timely accessibility (Marutha, 2018). Medical information is required during business audits (Ngoepe, 2012; Ngoepe and Ngulube, 2016), justice service delivery (Ngoepe and Makhubela, 2015), healthcare services (Katuu, 2015; Marutha, 2011; Marutha, 2016), investigations, monitoring and evaluation, and inspections (Marutha, 2018). Other functions or activities that require patents records are in regard to business accountability in terms of budget expenditure, income, profit and defence against litigation, as well as the provision of responses to information requests (Marutha, 2018).

In healthcare institutions, medical information must always be accessible to medical practitioners to enable them to provide timely services to patients (Luthuli and Kalusopa, 2017; Katuu and Van der Walt, 2016). Properly preserved records should always be secured and properly classified, with access controlled and obtained only with the necessary authorisation and/or rights. This is regardless of whether the records are electronic or paper-based. In a situation where medical records are not properly preserved, it is difficult or even impossible for healthcare practitioners to access them while rendering services to patients (Marutha and Ngoepe, 2017; Marutha and Ngoepe, 2018; Marutha, 2018). This study investigated strategies for the preservation of medical records and recommended a framework that medical practitioners, including doctors and nurses, may adopt to ensure that patients’ medical records/histories are at their fingertips. According to Bantom, De la Harpe and Ruxwana (2016), “access to personal health records is an astounding challenge for both patients and healthcare professionals”.

This study was conducted in 40 hospitals in Limpopo, South Africa. Limpopo is made up of 12 provincial departments, including the Department of Health, which is the focus of this study. The province is divided into five districts, namely Capricorn, Mopani, Sekhukhune, Vhembe and Waterberg. Each of the five districts is made up of district hospitals and one regional hospital, except Capricorn district, which has two provincial hospitals, namely Mankweng and Pietersburg hospitals. The entire province has three psychiatric hospitals, namely Hayani Hospital, based in the Vhembe district; Thabamoopo Hospital, in the Sekhukhune district; and Evuxakeni Hospital, in the Mopani district. Focusing on the number of hospitals per district, Mopani has eight, Capricorn has nine, Sekhukhune has seven, Vhembe has eight and Waterberg has eight. These hospitals report to the provincial Department of Health, which is also overseen by the national Department of Health. The core business of the Department of Health is to deliver public healthcare service in the province of Limpopo. This function is delegated to the districts and hospitals in different areas of the province, where people can access the healthcare service on a daily basis. In rendering healthcare services to citizens on a daily basis, all these hospitals create patient records. These records need proper management, as they are created daily and they affect hospitals, their employees and patients directly (Marutha, 2018; Marutha and Ngoepe, 2018; Marutha and Ngoepe, 2017).

The problem that led to this study was the difficulties that healthcare providers experienced in locating and retrieving patients’ records due to the current manual preservation strategies, the shortage of staff and constricted budgets at the public hospitals in Limpopo. The situation is chaotic, since the paper-based records are the only reliable source of patients’ medical and health histories, and there are no backup, safety and security measures or disaster preparedness measures in place to ensure their preservation (Marutha, 2016). This negatively affects the work of the healthcare provider and directly impacts on the health of patients because medical records become impossible to locate. Healthcare providers may not render services to patients who are experiencing problems, especially chronic patients, who need to be treated for different diagnoses with prescriptions for various medications (Luthuli, 2017; Marutha, 2016; Marutha and Ngoepe, 2017; Luthuli, 2017; Luthuli and Kalusopa, 2017). Patients also have to wait unnecessarily long for service, since officials are struggling to locate and retrieve their files. In some instances, files are retrieved and provided to physicians, who find that the necessary records are missing (Marutha, 2016; Marutha and Ngulube, 2018). The current mode of preservation, as discussed in this background to the study, may lead to hospitals losing patients’ medical and health history records permanently, since they are not backed up and not secured or kept safe.

Medical records preservation

Preservation strategies refers to strategies used in the preservation of records with an intention to “enhance and prolong” their usability for the required lifetime (lifecycle) (University College Cork (UCC) 2019). Strategies for the preservation of medical records include trusted digital repositories (TDRs), refreshing, backup and byte replication, emulation, encapsulation, migration, normalisation/conversion, cloud computing and using application programming interfaces (APIs) and preservation file formats (Magama, 2017). Trusted digital repositories provide long-term security and maintenance to digital records (Adu, 2015; Ngulube, 2012; Magama, 2017). Refreshing facilitates data copying from one medium to another, without any degradation (Adu, 2015; Magama, 2017; Rinehart, Prud’homme and Hout, 2014). Byte replication brings about file multiplication and storage to different systems (Adu, 2015; Magama, 2017). Backup has to do with making multiple copies and storage in different locations, far apart from each other (Magama, 2017). Emulation is a strategy used mostly during migration (Ngoepe and Van der Walt, 2009; Magama, 2017), replicating a previous system that is obsolete (Lowry and Nduna, 2015; Magama, 2017). Metadata is the data that is captured with the digital records to describe each of them in isolation from other records (InterPARES 3 Project, 2013; Magama, 2017). Encapsulation involves maintaining digital records in their original form, with appropriate metadata relating to them (Thomas, 2006; Magama, 2017). Migration has to do with the transfer of records from an old system to a newly adopted system for recordkeeping (Lowry and Nduna, 2015; Magama, 2017). Normalisation has to do with conversion of “digital records to standard format” that is open for preservation (Magama, 2017). Cloud computing is about keeping records in the (cloud) storage hosted by a third-party company (Magama, 2017). APIs bring about an interface for easy access to social media recorded information (Digital Preservation Coalition, 2016a). Using preservation file formats has to do with the consideration of the format of records upon preservation (Magama, 2017).

“It is quite evident that data storage in a safe and reliable manner is a top priority for health care organizations” (Bell 2018). A strategy for the preservation of patients’ records is therefore very important to ensure that records are preserved in such a way that they are available, accessible and in good condition for as long as they are required. This is also the case with electronic records, especially in relation to records migration between systems, since technology changes from time to time. An organisation should strategise to ensure that, even if technology changes or becomes obsolete, or if records change owing to the organisational structure, the quality and characteristics of the records are maintained and the risk of losing records is minimised (Ismail and Jamaludin, 2009). The best approach to records preservation, especially for an organisation or government body with many institutions under its control, is to ensure proactively that records are organised in paper and digital formats and mediums. Paper records may be organised and preserved locally at institutional level and digital records, from all the institutions, may be preserved centrally, through the proposed cloud computing solution offered here, under the control of the central higher-level government body, using standardised hardware and software (Asogwa, 2012; Decman and Vintar, 2013).

Should healthcare institutions insist on the paper-based medical records format and medium, different preservation strategies may be applied. Preservation of paper-based records involves many labour-intensive activities, including safe and secure storage, with appropriate materials and equipment to minimise damage and theft, and the backup of patient files by copying or digitising of records for possible recovery, damage repair and humidification. Paper-based records preservation is determined by, among other things, the quality of paper, the media used and the condition of the storage facility (National Archives of Australia, 2019). The paper-based records need to be properly classified and handled, filed in safe and secured storage facilities, for prolonged ease of retrieval/access, and backed up in offside storage facilities. The environmental qualities of the storage facility or location are crucial (State Archives, Minnesota Historical Society, 2009; UCC, 2019).

It would be ideal for healthcare organisations to shift from paper-based recordkeeping to a completely digital records creation and management system by converting their current paper-based patient records to digital images by scanning and capturing them into the electronic system, with metadata attached to each record image. This would give them the advantage of shifting to digital records storage options like cloud computing. Dhilawala (2018) provides the following explanation of what cloud computing entails:

Cloud computing is a flexible solution that allows hospitals to leverage a network of remotely accessible servers, where they can store large volumes of data in a secure environment that is maintained by IT professionals. Since the introduction of the electronic medical records (EMR) mandate, health care organizations across the United States have adopted cloud computing solutions as a means of storing and protecting patient electronic medical records system(EMRs).

Bell (2018), elaborates further, explaining that “nowadays, there is a growing trend of storing all kinds of data, including our medical records, on the cloud. People and organizations lease or buy storage capacity from providers to store all sorts of data in the cloud”. Cloud storage provides an option for organisations like healthcare institutions to store their patients’ medical data or records online, through cloud server hosting service providers such as Google Drive and Dropbox (Stephens, 2018).

Cloud storage refers to a model of rendering service for maintenance, management, remote backing up and provision of access through online computer networks to relevant users or recipients (Lelii, 2016). Decman and Vintar (2013) state that using the cloud as a records preservation method is a good strategy for the administration, management, preservation and archiving of public records, describing it as a type of “centralised technological solution for intermediate preservation and archiving”. This strategy is especially suitable for hospitals in respect of the centralisation and sharing of medical records, the preservation of patients’ records, access to patient records and archiving technology. It enables hospitals to handle records preservation properly on a physical, logical and conceptual level (Marutha, 2016). This ensures the trustworthiness of records when they are forwarded to an archive repository. The cloud can be used as a cost-effective electronic records centre in terms of maintenance and the sharing of records of all categories, be they active, semi-active and inactive records (Decman and Vintar, 2013). “Many healthcare providers are diverting to cloud-based data storage because of the promise of significant savings,” according to Bell (2018). It can be a better records preservation strategy/solution than having separate preservation solutions at each hospital, which can be costly in terms of staff and other resources. The cloud mode of records preservation can be even more effective when it is utilised in conjunction with modern information technologies and a fast Internet connection (Decman and Vintar, 2013). Bell (2018) comments on the merits of this solution as follows:

For large healthcare organizations, managing patient records in different files can be way too challenging without the help of a powerful technology. Pulling out physical files from its storage area wastes precious resources in time and money, adding a significant cost in employee expenses.

The government needs to establish and manage its own centralised records preservation repository. It needs proactive support in terms of budget to ensure the smooth running of “digital preservation” and “risk management”. It also needs lifetime support to finance “personnel, hardware, software, management and other activities” that may threaten its successful operation (Decman and Vintar, 2013).

Different institutions or hospitals should have their own electronic document and records management systems (EDRMS), which should be connected to the government cloud system, making records storage and the sharing of all categories of records through the central repository system possible. Institutions should share infrastructure (hardware), to handle the physical level of records, and software to handle the logical and conceptual levels of records (Marutha, 2016; Decman and Vintar, 2013). Cloud storage will provide all hospitals with a “secured network to transfer, store and manage documents” in a remote central geographical location (the cloud). By “clouding” patient files to ensure records preservation, the institutions will be sharing infrastructure, service architecture, software and records management related to their service delivery responsibilities. The establishment and management of records by the central repository should be guided by the national archivist to ensure compliance, even when records with archival value are transferred to an archival repository system during disposal (Marutha, 2016). Relevant policies should also be developed to give guidance on the system processes (Decman and Vintar, 2013).

A central records preservation repository has several advantages and benefits and only a few known disadvantages. The first advantage is that the establishment of a repository will be cost-effective, since the government or the sharing institutions may simply establish it on their own (Zhang et al., 2018). Dhilawala (2018) also identifies several advantages of cloud computing, including efficiency of storage, streamlining collaborative patient care, reduction in storage costs, high data security, ease of big data storage, easy flexibility and scaling, enhanced patient safety and medical research, and the interoperability of data. This may result in saving time in rendering healthcare service and require less physical records storage. Establishing a central repository could lower the cost of information technology (IT) management, since IT employees, equipment and costs will be shared by the institutions, and reduce the duplication of records per client, regardless of where a client was assisted/served (Marutha, 2016). The infrastructure costs will be reduced, since the institutions will be sharing a communication network. Access to records in the repository will be limited to only authorised people from the relevant institutions, and the repository may be accessed at any time and any place, using different devices, including mobile technologies such as computers, smart phones and tablets (Decman and Vintar, 2013).

The only disadvantage of a central records preservation system is that, if it fails, it will affect service delivery for all the institutions simultaneously. The government would have to address issues relating to security, network dependency to access records, the service quality and availability of the cloud, bottlenecked bandwidth, compliance with guiding regulations and standards, and a cloud computing risk management programme. To avoid even more risks, the government should adopt a community cloud that would be managed and used by the institutions concerned (Decman and Vintar, 2013; Marutha, 2016). Data migration and system conversion must also be taken into account when designing a system for records preservation. The system must be designed in such a way that records remain authentic, reliable and usable for their entire lifespan, even if the system changes. Changes to the system may include system format conversion to modern appearance format and data migration from one type of system hardware and software to another. This is to ensure access to and the reuse of the same or old data from the old system in the new technological system (International Organization for Standardization (ISO) 15489-1, 2001; Duranti, 1999; Lin, Ramaiah and Wal, 2003).

Records management staff will have to be trained in the old and new system formats, to ensure they have the skills needed to recommend the right system and can implement and test migration efficiently. During formatting, some data might be corrupted or lost forever (Marutha, 2016; Asogwa, 2012; Lin, Ramaiah and Wal, 2003). A lack of migration strategies for e-records, to deal with data that is corrupted or lost in the process, is one of the challenges identified by the Eastern and Southern Africa Regional Branch of the International Council on Archives (ESARBICA) (Marutha, 2016; Wamukoya and Mutula, 2005). A survey conducted in Namibia revealed that government officials experienced challenges in accessing records transferred from old software and hardware (from FoxPro to Oracle), because the new system was not tested before data alteration or loss (Nengomasha, 2009). This is the stage where the content of the old system is imported into the new system. During this process, quality assurance for transferred data is vital to avoid errors in the new system. Converting electronic records to non-proprietary electronic formats is easy to organise, cheaper for storage and more conducive to ensuring easy access to records (Chester, 2006).

In an electronic records management system, metadata is the information about the records that are electronically captured in the system; this information is used to manage those records. Metadata is used to identify or describe records in relation to other related or similar records (Ismail and Jamaludin, 2009; National Archives and Records Service of South Africa (NARSSA), 2006). ‘Metadata’ is defined, in MoReq2 (2008, p. 168), as: “Data describing context, content and structure of records and their management through time.” The information contained in an audit trail can also be considered metadata. Metadata provides a description of records in terms of, among other things, characters, “identity, authenticity, content, structure and management requirements” (Ismail and Jamaludin, 2009). Other examples of metadata are: date of records creation, transaction date, volume number and much more, depending on the organisational needs for access control and security in relation to records or intellectual property (Moreq2, 2008).

Aim of the study

The aim of this study was to investigate strategies for the preservation of medical records in the Limpopo hospitals in South Africa and bring about a framework that healthcare institutions may use to ensure that they have their patients’ medical records/histories at their fingertips (readily available).

Methodology

This section contains information about methodological approach to the study, which relates to the population, sampling, data collection design and instruments, data analysis and validity and reliability.

Population and sample

This multi-method study used a survey research design to collect original data in a very big population (Babbie and Mouton, 2001), from different hospitals in Limpopo, to study the perceptions, feelings, knowledge, preferences and behaviour of the population towards patient records preservation (Fink, 2013). Stratified random sampling was used in this study, to collect data using a questionnaire, which was augmented with observation, system analysis and document analysis, at 40 state hospitals in the province of Limpopo, in South Africa. The population was framed, stratified according to districts and job positions, levels 4 to 12, and randomly selected using the provincial Department of Health human resources staff establishment Microsoft Excel spreadsheet. Details about the names of the hospitals are presented below. The population of the study for the application of the questionnaire included records management officials and heads of clinical, nursing and records management units. The total sample for the study was 306, which represented 49% of the total population of 622. The sample size was determined using a Rasoft sample size calculator, with a 4% margin of error and 95% confidence level. A total of 217 respondents provided feedback to the questionnaire, representing a response rate of 70,9%. The hospitals covered by the study are listed as follows under each relevant district in Limpopo, South Africa:

1. CAPRICORN DISTRICT	2. SEKHUKHUNE DISTRICT	3. WATERBERG DISTRICT
Pietersburg Provincial Hospital Mankweng Provincial Hospital Seshego District Hospital WF Knobel District Hospital Botlokwa District Hospital Helen Franz District Hospital Lebowakgomo District Hospital Thabamoopo District Hospital Zebediela District Hospital	St Rita’s Regional Hospital Jane Furse District Hospital Matlala District Hospital Mecklenberg District Hospital Groblersdal District Hospital Philadelphia District Hospital Dilokong District Hospital	Mokopane Regional Hospital Voortrekker District Hospital George Masebe District Hospital FH Odendaal District Hospital Thabazimbi District Hospital Ellisras District Hospital Bela Bela District Hospital Witpoort District Hospital
4. MOPANI DISTRICT	5. VHEMBE DISTRICT
Letaba Regional Hospital Kgapane District Hospital Van Velden District Hospital Dr CN Phatudi District Hospital Maphutha Malatjie District Hospital Nkhesani District Hospital Sekororo District Hospital Duiwelskloof Hospital	Tshilidzini Regional Hospital Siloam District Hospital Usina District Hospital Malamulele District Hospital Louis Trichardt District Hospital Elim District Hospital Donald Fraser District Hospital Hayani Psychiatric Hospital

Data collection design and instruments

This multi-method study collected data using a questionnaire and through observation, document analysis and system analysis. The self-administered survey questionnaire was used as the main data collection tool (Fink, 2013; Singleton and Straits, 2010), which contained both open- and closed-ended questions (Fink, 2013). The researcher observed the medical records preservation and management strategies used in the organisations concerned. The records management and healthcare system were also analysed to ascertain the preservation of electronic records as to the safety and security as well as functionalities covered by the system. Policies and procedures were also analysed to see if there were guidelines regarding the preservation of records.

Ethical considerations

In observing the ethics for research, the researcher requested and was granted permission to conduct the study in the Limpopo provincial Department of Health hospitals by the Head of Department. A consent form was also given to participants to sign, with an introductory statement regarding the study and its purpose.

Data analysis

Data was analysed thematically, in line with the themes of the study, and presented using graphs and tables. The data collected led to the development of the proposed framework presented in the recommendations of the study.

Validity and reliability

The researcher also pre-tested the questionnaire, to ensure that it collected the data as purposed or aimed at by the study. The pretesting was conducted in the form of a questionnaire, with guidelines for inputs, which was distributed to a limited number of participants to check for grammatical errors, relevancy and the logic of the questions, as well as the visual part of the tool. Feedback was provided, with significant inputs to correct the questionnaire. The inputs were effected, to improve the quality of the data collection tool.

Presentation and discussion of the findings

The findings of the study are presented and discussed in this section.

Strategies for the preservation of medical records in the Limpopo Province

The observation data reveal that, in the healthcare institutions in Limpopo, medical records were mostly managed manually. Almost all processes involved in the lifecycle of the medical records were discharged manually. The only part of the process that was performed electronically, was the production or issuing of file reference numbers used for filing and locating files. For the most part, however, medical records were created, administered and managed manually throughout their lifecycle, until their disposition. This created an increased likelihood of a delay in retrieving the file, of misfiling and of damage to the file during the service delivery process.

In the Limpopo hospitals, the contents of the medical records were also not well structured or properly put together (with reference to indexing and folio numbering) for easy monitoring, detection and control of missing records, as confirmed by 89,9% (195) of the respondents (refer to Table 1). Only a few respondents 9.2% (20) stated that medical records files contents are well structured and arranged for easy monitoring and control of missing records (indexing and folio numbering) and 9% (2) respondents were unsure (refer to Table 1). In analysing the medical records (documents analysis), the researcher found that the file contents were not visibly structured, with no indexing and pagination to ensure proper management of the file contents. This was attributed to an immense filing and retrieval backlog, a shortage of staff or the high vacancy rate.

Table 1.

Medical records preservation (N = 217).

MEDICAL RECORDS PRESERVATION		RATING
MEDICAL RECORDS PRESERVATION		AGREE	UNSURE	DISAGREE
1. The medical records are well arranged and filed on the shelves according to the file numbers.	NO	67	24	126
	%	30,8	11,1	58,1
2. All the records are kept inside folders/covers and boxes to avoid misfiling.	NO	159	8	50
	%	73,3	3,7	23
3. The medical records files contents are well structured and arranged for easy monitoring and control of missing records (indexing and folio numbering).	NO	20	2	195
	%	9,2	0,9	89,9
4. The temperature in the filing storages is controlled for safety of the records.	NO	46	7	164
	%	21.2	3.2	75.6
5. The medical records are backed up with electronic records system for any disaster recovery.	NO	19	24	174
	%	8.7	11.1	80.2
6. The electronic recordkeeping technology makes it easy to manage the records.	NO	18	11	188
	%	8.3	5.0	86.7
7. The medical recordkeeping buildings are purposely built for recordkeeping.	NO	33	14	170
	%	15.1	6.5	78.4
8. The medical recordkeeping buildings are suitable for records custody.	NO	31	33	153
	%	14.3	15.2	70.5
9. The records custody is not easily accessible for unauthorised people.	NO	143	6	68
	%	2.8	65.9	31.3
10. It is easy to retrieve records in the custody.	NO	52	25	140
10. It is easy to retrieve records in the custody.	%	24	11.5	64.5
11. There are registers or system to track when records are removed from the records custody.	NO	83	11	123
	%	38.2	5.1	56.7
12. There are effective security measures for records in the custody.	NO	45	8	164
	%	20.8	3.7	75.5

Note. NO = Number, % = Percentage.

Although security measures were weak, the records custody was not easily accessible for unauthorised people as confirmed by 65.9% (143) respondents. Only a few 31.3% (68) respondents stated it was easily accessible and 2.8% (6) were unsure. This is because the records custodies were under lock and key at all the times. There were no effective security measures for general records hazards in the custody as confirmed by 75.5% (164) respondents. Only a few 20.8% (45) stated there was effective security measures and 3.7% (8) respondents were not sure. For instance, the temperature in the filing storages was not controlled for safety of the records as confirmed by 75.6% (164) respondents. Only a few 21.1% (46) respondents said it was controlled and 3.2% (7) were not sure. The other weakness was that the medical records were not backed up with electronic records system for any disaster recovery, as confirmed by 80.2% (174) respondents. Only a few 8.7% (19) stated it was backed up and 11.1% (24) respondents were not sure. Table 1 presents the summary of the data. The data obtained through observation also showed inadequate safety and security measures in relation to custody of the records, specifically regarding measures to mitigate defective ventilation, unauthorised access to registry rather than records storage and disaster management: there were no backup files, functional air-conditioners, designated officials assigned as custodians of the medical records and the filing system, water leak detectors and carbon dioxide fire extinguishers. Some of the records storages had water pipes passing over them and basins inside the storage facility. Some records are filed along the corridors, due to a lack of storage facilities and congestion in the available storages. The medical recordkeeping buildings were also not purposely built for recordkeeping as confirmed by 78.4% (170). Only a few 15.1% (33) stated they were purpose built and 6.5% (14) were not sure. The medical recordkeeping buildings were not suitable for records custody as confirmed by 70.5% (153). Only a few respondents (14.3% (31) stated they were suitable and 15.2% (33) were not sure. Table 1 summarises presentation of the data. The observation report shows that some recordkeeping buildings were converted from toilets or bathrooms and patients consulting rooms and still had some water pipes crossing and tabs inside with no required ventilation control measures.

The electronic recordkeeping technology was not making it easy to manage the records as confirmed by 86.7% (188) respondents; only a few 5% (11) stated it made it easy and 8.3% (18) were not sure (refer to Table 1). The observation data and system analysis data report that the patient records are mostly created in a paper-based format, while information regarding patients’ demographic/personal and billing/financial details is created and captured using the electronic patient administration information system named Provincial health information system (Phis). This was a very serious loophole, since the only information backed up is the demographic and billing information. The rest of the patients’ medical and health history was not backed up, since it was only created and kept in paper-based format. The document and system analysis report shows that paper-based records contain all the information captured in the electronic system, but also the medical and health history information about patients such as treatments, diagnosis, prescription and laboratory results, to list just a few, which was not covered in the Phis system. This was a very serious, high risk situation, because, should the paper-based records be destroyed, for any reason, there will be no back-up plan for the hospital. In addition, no records security and disaster preparedness measures were in place to mitigate against any disaster or perils that may occur at these records and storage facilities. The paper-based filing facilities are also chaotic, to the extent that some hospitals opt to file in pathways and corridors between shelves.

It was not easy to retrieve records in custody, as confirmed by 64.5% (140); only a few respondents (24%: 52)) stated it was easy and 11.5% (25) were unsure. There was no registers or system to track when records are removed from the records custody, as confirmed by 56.7% (123) respondents; only a few (38.2%: 83) stated they were available and 5.1% (11) were not sure. The data is presented in Table 1. The observation data reported that the paper-based records are managed manually, without appropriate controlling tools like registers, and the workflow protocols require that patients’ files are with patients as they move from service point to service point, which is a high risk, because patients do not know about records management and handling principles. Some patients may be mentally ill, some may be physically ill or injured and are vomiting or bleeding, which may affect the records or files in their possession.

In the Limpopo hospitals, the medical records were not well arranged and were not filed according to their file numbers, as confirmed by 58,1% (126) of the respondents. Only a few respondents (30.8%: 67)) stated that medical records are well arranged and filed on the shelves according to the file numbers and 11.1% (24) were not sure (refer to Table 1). The researcher believes that this response is due to the reason that many record files were kept on the floor between shelves or filing cabinets due to inadequate filing space, as also reported by observation. However, hospitals used folders/covers and boxes for keeping paper-based records, to avoid misfiling, as confirmed by 73,3% (159) of the respondents (refer to Table 1). Only a few respondents (23%: 50)) stated that records are not kept inside folders/covers and boxes to avoid misfiling. The observation data findings showed that even if some of the files were kept on the floor due to shortage of filing space, most medical records were kept in files/folders/covers and filed in boxes that were arranged according to the file numbers on the shelves. The observation also showed that most of the hospitals used mobile filing cabinets, while a few used static filing cabinets.

Metadata usage in the preservation of medical records

In the healthcare institutions of Limpopo, there was compliance with records metadata requirements, as confirmed by 56,2% (122) of the respondents, while 33.6% (73) stated there was no compliance and 10.1% (22) did not respond. For instance, when the researcher analysed paper-based files and Phis (electronic system used for patients’ administration), the medical records metadata was mostly captured in paper-based records and partially on an electronic system. Document and system analysis also indicated that the paper-based files contained information about the healthcare professionals who had assisted the patients, but, on the system, there was no data about the nurses, doctors and other specialists who had treated or prescribed medicine to the patients.

Conclusion

This study investigated a framework for preservation of medical records to bring patients’ medical records/histories to the healthcare providers’ fingertips (readily available). Records preservation, especially medical records, is always very difficult in a manual mode of operation. This is especially true for healthcare institutions that experience a high demand for healthcare services or that serve an area with a very high population. Furthermore, strategies for the preservation of medical records are not only limited to keeping and maintaining medical records, but there are more strategies in existence. The preservation strategies apply from the beginning of the process, when records are created in the process of healthcare service delivery, and they continue to apply throughout the lifecycle of the records, until their disposition. This implies that, for the records to be properly preserved, with no margin of error and no omissions, a framework is a necessity to guide the process of records preservation. The format of the records created has a significant effect on the extent to which they are finally preserved, classified, filed, maintained, secured, accessed and disposed of. Records need to be created in a form or format and medium that will allow proper custody and maintenance throughout their lifecycle. These are some of the key issues that institutions must pay attention to in their endeavour to improve the preservation of medical records in their healthcare facilities. They will also need to research and identify risks, disadvantages and advantages of the preservation strategies and systems that they want to adopt, prior to adoption, in case of digital records.

Recommendations

It is vital that the healthcare institutions in Limpopo consider moving from a paper-based manual system to an electronic mode of managing their medical records and, where possible, ensure that their medical records are created digitally. This is unlike creating records manually and converting them to digital or electronic format, since that nullifies the originality of the records, as in the case of the records currently in custody. The only records that may be kept and managed manually are backup copies, which may help institutions to recover files should a disaster occur. This implies that medical records must be created, administered and managed electronically, throughout their lifecycle, until their disposition. The aim of such an approach is to protect medical records against loss, misfiling and erasure, and to ensure their easy retrieval by the relevant officials. If an electronic system is used to perform activities relating to the administration of medical records, including classification, the likelihood of errors will be reduced. This may lead to improved healthcare service delivery, since medical records will be easy to monitor, locate, control and retrieve, anytime and anywhere, depending on the kind of system applied. In an electronic operation environment, records and data are simply accessed and updated using smart phones, tablets, laptops and desktop technology, depending on what is the most convenient for service providers.

As underscored by State Records New South Wales (2004) and Ndenje-Sichalwe, Ngulube and Stilwell (2011, p. 269), after the files have been captured by the officials, it will then be the responsibility of the applied electronic system to do everything regarding medical records management to ensure that the records are automatically classified and categorised, systematically and consistently. This kind of system therefore facilitates the capturing, retrieval, maintenance and disposition of medical records. The manual classification scheme currently utilised in the healthcare institutions in Limpopo will have to be automated and embedded into an electronic medical records management system. An electronic medical records management system, if properly implemented, will solve many of the current problems manifesting in healthcare institutions and lead to improved healthcare service delivery. For instance, an e-system will take over the current arrangement, maintenance and conservation of medical records and reduce the need for physical storage space. In other words, records will no longer have to be filed on the floor, between shelves. Instead, electronic files or folders will be applied for the proper arrangement of records, according to unique identifiers and subcategories. Instead of filing cabinets, electronically appropriate servers must be used for the effective storage of valuable medical records. The healthcare institutions must consider transferring metadata that has been used for manual paper-based medical records to an e-system, after which the metadata must be embedded into the e-system. Metadata elements that were omitted in a manual system may be effected when a new electronic medical records management system is adopted or when an existing electronic system is enhanced.

Proposed framework for preservation of medical records in public health

It is imperative to provide a framework that may be used as a benchmark by healthcare institutions to improve their records preservation strategies. Figure 1 presents a proposed framework for medical records preservation throughout the process of healthcare service delivery, in an attempt to guide healthcare institutions and provide them with such a benchmark. The framework was developed, based on the findings of the study, to guide the implementation of recommended improvements for preservation strategies. The framework is flexible and may be refocused, according to institutions’ own local needs. As indicated in the framework, there is a need for the institutions to ensure that they implement different kinds of safety and security measures for medical records, throughout their lifecycle. The institutions also need to create and ensure the implementation of governance tools such as policies and procedures to govern the way officials create medical records throughout the workflow of healthcare service delivery, as well as in relation to the capturing, classification and maintenance of medical records, throughout the preservation process during their lifecycle. The major focus is to ensure that medical records are safe and secure throughout the process of healthcare service delivery and that they can be readily accessed by and shared between appropriate officials or individuals. The framework is aimed at ensuring that the medical records created by one healthcare institution can be accessed by and discussed with other institutions, and that the first institution visited by a patient creates a file only once. The other institutions just add or update medical information, as the patient visits them, for other health-related matters, instead of opening or creating a new file. For this reason, as illustrated in Figure 1, a second server, located centrally, has to be used by all healthcare institutions, to share medical records in the course of their business process.

Figure 1.

Framework for medical records preservation throughout the process of healthcare service delivery.

This framework may serve as a tool for healthcare facilities to reconfigure their medical records preservation system. Timely access to patients’ medical histories is crucial for the successful delivery of healthcare services to patients and for the survival of patients who are fighting illnesses that need to be treated progressively. Hence, strategies for the preservation of medical records that support healthcare service delivery in the public sector and ensure that healthcare providers have the medical histories of patients at their fingertips should be considered a key priority.

Footnotes

ORCID iD

Ngoako Marutha

Appendix

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