IMPACT OF COMPUTERIZED PHYSICIAN DOCUMENTATION IN SOME SELECTED GOVERNMENT AND PRIVATE HOSPITALS IN KANO STATE

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ABSTRACT

ABSTRACT
The objective of this research is to find out the impacts of computer usage by physicians in Kano State and this is likely to increasingly replace handwritten documentation in other institutions. The population consisted of the physicians in Kano state hospitals. A questionnaire was designed and administered among 26 physicians using a simple random sampling technique. Simple percentage was used to analyze the research questions.
The study found out that the physicians in Kano state need to do more to make for a proper electronic health record keeping in their hospitals. Training of staff on computer knowledge explained the reason for using a Personal Digital Assistant (PDA) to patients and finally, carefully designed and implementation of any electronic health record system should be a priority.

CHAPTER ONE

INTRODUCTION

CHAPTER ONE
1.0 INTRODUCTION
The effectiveness with which information needed by organization is generated and transferred is used to determine the rate of progress of a society. Modern society is information conscious. Organization and even the hospitals in the communities are not left behind.
The society depends on information for their smooth running and survival. For this reason, information must be well managed.
Generally, the management of patients’ records and even that of the clinic staff record (collection of related fields – data) relating to patients and staff such as name, age, sex, age, sex, origin, health condition, symptoms etc. which when carefully selected, manipulated, organized and communicated in some meaningful ways become information.
The researcher in particular tends to investigate into the impact that computerized documentation plays in the selected hospitals in Kano state. The data collected will reflect the result of clinic staff in the selected hospitals in Kano state and will be used to generalize and present the experience of those in that sector.
1.1 BACKGROUND OF THE STUDY
Some years back, Nigeria as a nation has little number of physicians with the knowledge of computing documents, all they knew was paper-based (hand-written) documentation in all their day-to-day activities.
Today, few medical practitioners still find it difficult to effectively use computer despite the technological development and the access they have to computer in their offices.
This study, when completed would encourage both the resident and faculty health workers including the nurses on the use of computer in documenting their records. It will also help to highlight the problematic areas and provide ways of improving the ability to using computer-based documentation in hospitals; in this regard it would also help the students and other researcher on similar research topic to have insight and guide on the impact of computerized physician documentation in the hospitals with particular reference to this area of study.
1.2 PURPOSE OF THE STUDY
The purpose of the study is to identify the effects of computerized documentation in hospitals and the attitudes of those in that sector towards the use of computer.
The study also further intends to:
i. Examine whether the hospitals in question employ physicians who are computer literates and compare them to those without computer knowledge.
ii. Find out whether the nature of daily routines carried out in the hospitals encourages the use of computer in documenting most records.
iii. Find out whether the result generated by the computerized documentation suites the format expected by the health workers.
iv. Find out whether the introduction of the computerized documentation reduces the rate of interpersonal communication among the health workers.
1.3 STATEMENT OF THE PROBLEMS
The absence of complete accurate physician documentation continues to pose concern for hospital providers. Being in compliance and ensuring accurate record keeping (i.e. computerized or manual). However, the correct application of coded data depends heavily on physician documentation; which has been shown to be deficient.
Compliance struggles with physician’s documentation typically stem from physicians who inadvertently do not understand the methodology behind coding and how documentation or the lack of it, affect coding and billing. The key to ensuring appropriate documentation depends on physicians’ understanding of coding methodologies and its clinical interpretation.
The importance of documentation
Proper physician documentation is important many reasons. It should serve as a means to help physicians organize their thoughts, justify the treatment, support the diagnoses, and document patients’ progress and results of treatment provide continuity of patient care by serving as a vehicle of communication for care givers to evaluate, plan and monitor patients’ care plans.
Because of the potentials for important effects from the use of computerized physician documentation (CPD), the likelihood that this technology will proliferate, and the paucity of research to it use in the inpatient setting, this study set out to identify the range of clinical and educational impacts that are perceived to have been caused by the transfer from manual to computerized record keeping in hospitals.
1.4 RESEARCH QUESTIONS
The following questions are therefore calling for answers to ascertain the fact of these propositions:
i. Is there any difference in the use of computer in documenting records in the hospital compared to the conventional paper-based (hand written)?
ii. Will the introduction of computer in a hospital consultation rooms increase the interpersonal relationship between patients and physicians?
iii. Is there any relationship between the background of the physicians and the use of computer?
1.5 SIGNIFICANCE OF THE STUDY
In daily documentation and maintenance of medical record and quality is a crucial issue in hospitals. The overall quality of the health records could be enhanced with the use of electronic devices (computers).
Therefore, this study’s significances are the following:
i. It is hoped that the findings of this study will help the hospitals authorities to device the way to change the trend of the attitude of physicians towards the use of computer.
ii. It is hoped that recommendations that emerge from this study will allow for assessing the effect of different computer placement in the hospitals.
iii. The findings of the study will be used to improve the reliability of measuring the impact of computer system in the consultation room for documentation.
1.6 SCOPE OF THE STUDY
With regard to the research subject, it will be of mentioning the extent at which the tentacles of the research worker will go in the area of study to gather information and the sections of the hospitals that can be used.
Firstly, as the name or the research topic is based on the physicians (doctors) this then call for the fact that only the physicians and very few other health workers will be consulted for gathering information.
Secondly, the attitude of the physicians towards the use of computer that will be studied may not be extraneous due to the factor in the completion of the work.
1.7 LIMITATION OF THE STUDY
This study has some limitations. Data was collected from few hospitals in Kano state which represent sample of the numerous variables that can be tested on the subject matter. The results may not be generalized beyond Kano state hospital involved, to other specialties or to the outpatient setting.
1.8 DEFINITION OF TERMS
CPD: means Computerized Physician Documentation which is the physician’s records stored, processed, analyzed, or generated by computer.
Physician: This is a licensed medical practitioner.
EHRs: means Electronic Health Records which is some how synonymous to CPD an electronic method of storing records in the health sectors.
CPRs: mean Computerized Physician Records.
Documentation: Program listings or technical manuals describing the operation and use of programs.
Patient: A person who requires medical care.
PDA: Personal digital assistant is a lightweight consumer electronic device that looks like a hand-held computer but instead performs specific tasks; can serve as a diary or a personal database or a telephone or an alarm clock etc.
Hospital: A medical institution where sick or injured people are given medical or surgical care.

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